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November 10, 2009
Big Medicine is published by Team EMS Inc.
The views expressed here reflect the views of the authors alone, and do not necessarily reflect the views of any of their organizations. In particular, the views expressed here do not necessarily reflect those of Big Medicine, nor any member of Team EMS Inc.
VIEWS: JIM RUSH
[October 19 2009]
Purchasing, Managing and Distributing Federal Reserve Inventories
Elected officials, emergency managers, healthcare executives and public health officials are focused on protecting and treating patients who are, or will be infected by the H1N1 epidemic.
Government procurement officials now understand that all the money in the world can’t buy medical products that are unavailable due to high worldwide demand. The government also is recognizing that when worldwide demand for any commodity is very high, the supply chain simply cannot keep up with orders. It is becoming very clear that governments need to build reserve inventories to accommodate sudden spikes in demand.
Currently, there is less understanding that if hospital admissions surge, there will be shortages not only for obvious products like anti-viral medicines, N-95 respirators and isolation gowns, but for every item hospitals use in treating seriously ill patients.
Thus, I thought I’d suggest a methodology of proactive purchasing, managing and distributing America’s emergency relief supplies in meaningful quantities to sustain the healthcare industry and community mass care facilities during large-scale, long duration disasters.
This recommended system uses professional supply chain managers, healthcare distributers and logistics companies to purchase, manage, transport, distribute and account for Federal relief supplies, equipment and vaccines.
The first thing we need to realize is there are two very different management approaches to acquiring and distributing medical materiel.
The second thing to realize is that the Private Sector Healthcare Supply Chain manages Just-In-Time inventories for normal medical product demand and there are no meaningful medical reserve inventories to supplement and sustain the Healthcare Industry during extraordinary spikes in demand for supplies, equipment or services.
1. Just-In-Time (JIT). The Private Sector healthcare supply chain managers do a great job in predicting the demand for medical materiel during normal times. During the past 30 years, supply chain computer models have become extremely accurate in predicting supply usage; locally, regionally and nationally. While “predictive computer demand models” can predict seasonal spikes in demand for medical items which are “cold and flu” season- based, no computer can predict spikes in demand for medical material for disasters and epidemics. This means in the Public Sector, there are no “Just in Case” Reserve Inventories of supplies, equipment or vaccines. America has a Strategic National Stockpile (SNS), designed to assist Public Health departments as they respond to public health needs, but the SNS was never designed to support and sustain America’s Healthcare Supply Chain. The difference between normal medical product consumption rates of medical materiel and the consumption rates associated with a large-scale disaster is astounding. From a National perspective, patient admissions are currently modestly elevated as compared with a normal influenza season. While there are backorders for selected medical products, these outages are manageable, at least over the short term. On the other hand, if we see a 50%-100% increase in seasonally adjusted patient admissions over time, the healthcare industry’s supply chain may not be elastic enough to surge manufacturing in time to meet the demand. It is becoming more and more obvious that the Government must plan to supplement medical materiel inventories for use by healthcare organizations during large scale and long term disasters. For maximum value and usefulness, these inventories should be purchased by the Federal Government under the Emergency Support Function (ESF)-8, Health and Medical Services, or ESF-6 Mass Care, Housing, and Human Services as described in the National Response Framework. It is less important which ESF Agency purchases, manages and distributes disaster-related medical materiel than it is to have serviceable medical products and services available when needed.
2. Reserve Inventories. Elected and appointed National leaders need to understand that “Preparing for unpredictable spikes in demand for medical items is predominately a Government responsibility.” Certainly, the Private Sector healthcare industry can help Federal planners develop stock listings of every medical supply and every item of equipment that will be needed during each planning scenario. This process is called “requirements development” and although it’s a bit tedious, requirements development is very easy to do. Developing requirements is easy but purchasing the medical materials and managing very high quantities of many individual supply line items without losing any items to expiration in storage, takes significant expertise and time. The good news is that healthcare distributors are among the best in the world at managing medical materials in storage and at moving those materials where and when they are needed. The only issues remaining are “who is going to purchase disaster-related medical materials” and “who is going to pay to manage these large inventories while they are held in reserve for future disasters.” The answer is easy, since Private Sector business cannot invest in inventories which exceed normal demand; the Federal Government must invest in Federal Reserve Inventories (FRI).
This does not mean that the Government needs to set up a parallel healthcare supply chain. Remember the healthcare supply chain is extraordinarily efficient at getting supplies and equipment from the manufacturer’s loading dock to healthcare organizations and retailers wherever they are needed. More importantly, the velocity of medical supplies flowing through the supply pipeline each and every day means the healthcare supply chain can rotate huge quantities of FRI if the Government would just purchase it.
The Federal Government, under either HHS under Emergency Support Function (ESF)-8 Health and Medical, or FEMA under ESF-6, should purchase FRI and entrust its management to Healthcare Distributors to manage and distribute it when authorized. Hopefully, the Department of Homeland Security (DHS) will determine which agency must support the FRI soon. For the purpose of this article, Federal Agencies will be referred to as “The Fed.”
By developing a FRI system, The Fed will assist healthcare and public health practitioners:
o Save lives
o Save money
o Meet the 48 hour HHS post-exposure mass prophylaxis requirement
o Improve stewardship of a National asset
o Improve operations, inventory tracking and asset visibility
o Reduce “in-transit” time to the affected jurisdiction’s healthcare organizations
o Facilitate much faster dispensing and vaccination
o Improve Public Health response
o Improve citizen acceptance
Managing and Distributing Federal Reserve Inventories (FRI) of Vaccines, Medical Supplies
1. Concept of Operations: The Fed will use established, mature and proven Healthcare Distributor Supply Chains to store, manage (stock rotation and quality control), and rapidly distribute and account for all FRI materiel during declared disasters or public health emergencies.
A. During normal operations: The Fed maintains oversight of all government owned materiel. They also develop and share with distributors, a list of participating dispensing centers/immunization centers, as well as Public Health and healthcare entities to be supplied with FRI materials during a disaster. Maximum order quantities and other formulas such as “priority dispensing entities” can be established during this period.
B. During Disasters: Upon requests from jurisdictional officials, The Fed releases FRI materiel into the appropriate healthcare distributors supply chains for distribution to the healthcare or public health entities requesting FRI.
C. Post Disaster Accountability: The Fed and the receiving jurisdiction’s chief fiscal officer obtains reports from distributors regarding which entities received FRI materiel by line item and dollar value.
(1) Distributor-provided FRI usage lists will serve as documentation for The Fed to request FRI replenishment dollars from Congress.
(2) The Fed will be able to quickly and easily develop post-disaster activity and accountability reports
2. Why use existing supply chains and logistics networks?
A. Healthcare Distributors have the knowledge, competency and experience of moving millions of dollars in medical pharmaceuticals, vaccines, medical materiel from manufacturers to customers every day.
B. Defense Logistics Agency (DLA) and the Department of Veterans Affairs (VA) and HHS’ Supply Service Center have already established Prime Vendor relationships with the Nation’s major pharmaceutical and medical surgical distributors-the framework is in place.
C. Distributor supply chains are already established and can do the job in an emergency.
D. All customers’ addresses are already in the distributors’ system, so the interface for sustainment during disasters will be seamless.
E. Distributors will be out of their normal operating stock during the disaster-related spike in demand. The Distributors’ workforce can then distribute FRI stock instead of closing shop.
F. During normal operations, manufacturer supplies flow through this pipeline- the FRI materials can flow through the pipeline just as smoothly.
G. Distributors have highly developed supplier relationships with:
(1) Pharmacy chains-Walgreen’s, Eckerd, CVS, etc.
(2) Public health clinics
(3) Military and VA hospitals and medical centers
(4) Hospitals and medical centers
(5) Nursing homes
(6) Assisted living communities
(7) Neighborhood health centers & urgent care centers
(8) Prison healthcare centers
H. Distributors have highly refined systems to interface with logistics and transportation companies and maintain long-standing relationships with:
(3) Many other National and International logistics companies
(4) Hundreds of other independent short and long-haul freight companies
(5) Thousands of courier services
(6) The FED should leverage this existing experience to obtain fastest point-to-point service during disasters.
1. Concept of Operations: Since the vast majority of Americans know where they normally get their medicines, use pharmacies for dispensing and physician offices and public health departments for vaccinations as the 1st tiers of the dispensing and immunization systems.
2. Why use the existing pharmacies as the disaster dispensing network?
A. Pharmacists know their clients
B. Pharmacies maintain automated records for all patients served in order to discover medication errors, contraindications, allergies etc.
C. Pharmacies are tied into distributor networks and have alternate distributor arrangements if one is out of stock.
D. Pharmacists know most of their clients’ family’s medical histories-this enables one family member to pick up courses of treatment for the entire family.
E. Pharmacies can provide numbers of clients served, number of courses of treatment filled, age mix etc., for post-event epidemiological studies.
F. Physician offices routinely provide immunizations and know those most in need
G. Physicians know their patient populations and can best prioritize which patients get immunizations first.
Public Health Departments can manage the event from a Public Health and not a distribution prospective.
1. Public health “At Risk” populations will receive better and more focused care, when the major portion of the population is being served through pharmacies, physician offices and other Healthcare organizations.
2. Public health departments will be unburdened by serving Public Health clinics and facilities only.
3. Public health staff can be utilized in public health activities instead of trying to compete with distributors.
4. Public Health will have more Post-Disaster time to perform studies on the effects of the disaster, instead of reconciling bottles of medicines received to doses/vaccinations given to the entire population.
5. Public Health officials can focus on anomalies and exceptions, instead of trying to manage distribution, dispensing and post event accountability.
6. Public Health personnel are freed to provide a full array of public health services
1. This initiative will provide better FRI management and distribution using very sophisticated inventory management systems. The FRI will:
A. Remain perpetually fresh with state of the art stock rotation systems.
B. Maintain its identity in storage as “Government Owned Material” (Ownership code “FRI.”
C. Be ready for shipment in minutes-not hours.
D. Be transported through an operationally tested transportation system of ground and air transporters as well as local couriers.
E. Arrive at the right place within the shortest timeframe using established, redundant transportation systems.
F. Get to exposed Americans and to Healthcare organizations within hours.
2. This initiative will also:
A. Meet HHS’s 48 hr. requirement for biological agent post exposure prophylaxis
B. Provide the safest dispensing system for detecting contraindications, allergies etc.
C. Provide timely feedback to FDA on adverse reactions and rapid transmittal of FDA Type I, II and III material complaints
D. Provide better stewardship and accountability.
E. Provide the fastest emergency movement, distribution, and dispensing of lifesaving pharmaceuticals, equipment, supplies and vaccines anywhere they are needed nationally and internationally.
A stimulating idea: Using economic recovery dollars to build disaster healthcare readiness and re-employ workers
by Jim Rush
[July 5 2009]
The American Recovery and Reinvestment Act of 2009, appropriated approximately $787 billion aimed at turning around the American economy during this deep recession. There have been a number of criticisms that these dollars will fall into a number of economic “Black Holes” and provide only temporary results. There is a wonderful alternative.
Recently, I saw a TV interview with Michigan’s Governor Jennifer Granholm discussing the profound downsizing of America’s automobile industry and the devastating effect this is having on countless highly skilled Michigan auto workers. I felt badly for both the Governor and the unemployed Michigan workers. I had the idea that Americans can obtain badly needed mobile disaster hospitals and specialty centers for future disasters, and at the same time put unemployed Michigan workers back to work. Medical Support Equipment and Supplies Manufacturers across America would also benefit. . I have sent a detailed proposal to Governor Granholm and other Michigan elected officials I hope would be interested in this multi-purposed program.
I often wondered if there was a reason why I received very unconventional assignments in my career as a medical logistician. It started in the Air Force and when I left the Service, I remained in Germany, working as an Army civilian employee. I was responsible for supporting medical missions for both war and foreign assistance to Governments overseas during disasters. I was indeed very fortunate in being a part in building mobile medical units. I was even more fortunate in learning from some of the best Medical Readiness people in the Free World.
So what would be the benefits of rebuilding America’s disaster healthcare capabilities using mobile medical assets and support systems?
1. Save lives and lessen suffering. With a well developed mobile healthcare system, we can very quickly reinforce jurisdictions’ Public Health and Healthcare systems when they are in the Response and Recovery stages of a disaster. We all know that victims of hurricanes Katrina, Ike and Gustav had to receive (and many folks still are receiving) healthcare services far away from home.
2. Re-Train and Re-Employ highly skilled workers. My proposed program will train and re-employ tens of thousands of heavy industry and automobile workers in Michigan and in other jurisdictions all across America building mobile medical facilities and support equipment for sustaining these assets during deployment. These facilities and their sustainment packages can be used over and over and will provide long lasting disaster capabilities and enduring jobs during both the manufacturing stage. Afterward, these same workers can be employed in managing these assets in storage, reconstituting hospital and specialty units after each use, repairing equipment, provide maintenance in the field and in transporting and recovering these assets over their 25 years of useful life. The program will also, in fact, be a real and profound stimulus to all manufacturers of medical and support equipment and supplies as well. These mobile medical assets can be sold to our trading partners all over the world and will save countless lives during their many deployments.
3. Stimulate America’s Healthcare Supply Chain. With a real sense of urgency, we can immediately stimulate the healthcare supply chain for medical supplies such as wound, care, burn care, special needs supplies and the full line of medical-surgical consumable supplies. We can also stimulate manufacturers of medical equipment such as surgical and ER equipment, ventilators, patient monitoring equipment, and mobile digital imaging equipment, to name just a few.
4. Use underutilized manufacturing and warehousing facilities idled by the closing automobile manufacturing facilities. Why not re-tool auto plants to begin an entirely new and badly needed manufacture of mobile hospitals, special needs shelters, burn and trauma centers and all the associated support equipment like heavy-duty, long run generators, very high output water purification systems, regulated medical waste treatment equipment and mobile kitchens, just to name a few.
5. Develop the best disaster healthcare system in the world. These units look like hospital wards when they are erected. Sure, they can be augmented by tents for support functions like inventory control/ordering, food service and staff living quarters. But for patients, these facilities are perfect for providing definitive medical care during both the Response and Recovery stages of a disaster. The test I used when selecting these facilities was “Would I feel comfortable with a family member receiving a full continuum of health care including ventilator support in one of these facilities?” The answer was “Definitely.”
6. Provide huge savings to the Taxpayers in future disasters. Yes, savings on top of all the other benefits. Consider the cost of air evacuating patients and family member escorts out of the disaster’s jurisdiction to obtain healthcare at various health centers away from the disaster jurisdiction. That is still happening in Galveston and in some cases, may still be happening in New Orleans. Some entity is paying for this extraordinarily high cost, time-delayed healthcare. These mobile hospitals can be used, reconstituted and redeployed approximately 50 times. They will pay for themselves during their second deployment by providing definitive care instead of only stabilization at locations very near the disaster location. The next 48 deployments will return dollars to America and vastly improve healthcare during Response and Recovery stages. In fact, if we took my suggestion on these units in 2003, Hurricane Katrina and all subsequent hurricane medical responses would have looked far better and infinitely more laudable.
The 1960’s Disaster Healthcare System: During the Cold War, America built a robust Civil Defense Program which included 2,600 Packaged Disaster Hospitals, pre-positioned in strategic locations across America for wartime use.
Each of these packaged disaster hospitals contained 200 beds, a radiology section with a portable X-Ray machine and a 3-table operating suite. Each hospital also had sufficient consumable medical supplies to operate independently for 30 Days. These disaster hospitals gave America 512,000 beds, 7,800 operating rooms and 2,600 radiology sets for surge capacity for disasters or emergencies. Over time, a lack of funding of the Civil Defense program and materials obsolescence resulted in the decay and disposal of the disaster packaged hospitals.
Today, we have none of these capabilities. America has profound shortfalls in medical facilities and associated support capabilities that can be used during disasters.
There are no federal mobile medical assets that can be deployed to jurisdictions during disasters and very limited quantities of pharmaceuticals for biological events..
How can we justify being far less capable of providing healthcare and public health during disasters in 2009 than we were in the 1960’s? We just can’t!
We all know that America’s Healthcare System has been in crisis for over 20 years. A Pandemic, a terrorist attack such as a nuclear detonation in a large population center or any other very large even, will damage and may destroy America’s healthcare system as we know it today. We are seeing a serious lack of health services right now in Galveston, almost a year after hurricane Ike.
We can do the right thing, the compassionate thing and the smart thing by rebuilding our disaster medical system. I hope that all Emergency Managers including those at DHS/FEMA will support this vital initiative by forwarding this paper to their decision makers and supervisors.
Let’s put our fellow Americans to work building a disaster healthcare system capable of saving lives and demonstrating what we can do when we put our minds to it!
[May 7 2009]
On the heels of the 24 hour news coverage of the Swine Flu, I began thinking of what it might take to convince healthcare executives to re-examine the idea of “Medical Readiness” from a cost/benefit perspective. Let me lay out the benefits first, since looking on the positive side of this issue first is always best. We’ll get to the costs involved in failure later in the article.
1. Every Healthcare Executive knows that being the best healthcare alternative in their community means-success. Based on that safe assumption, the healthcare executive who has made a commitment to Healthcare Disaster Readiness will reap the following benefits:
a. Available services means revenues: Healthcare Organizations that have developed a “Corporate Culture of Disaster Readiness” will have the best chance of surviving a disaster and remaining profitable during and after the event.
b. FEMA Grant-Ready: Being “Disaster-Ready” also means understanding which types of recovery and/or mitigation assistance the healthcare organization may qualify for during the recovery stage. A thorough understanding of the FEMA Public Assistance (PA) guidance may translate into maximum eligible funding and shorter approval times. Armed with this PA knowledge, the healthcare organization can get back to providing health care, while competitors begin exploring FEMA eligibility criteria and application processes only when FEMA comes to town.
c. Standardization saves money: Healthcare Organizations can reap significant savings by standardizing medical products across the entire Health System and eliminating duplicative products. Fewer medical items (a leaner master item file) can mean better stock levels across the entire supply chain, more aggressive purchasing tiers and far better distributor fill rates during surges in product demand. The Armed Forces learned during the 1991 Gulf War that “preference items” were nothing but trouble for suppliers, medical logisticians and care givers. Private sector healthcare organizations can profit from this experience in more ways than one.
d. Defending the Healthcare Facility is always more cost effective than rebuilding the facility and recruiting new staff. When a healthcare organization fails during a disaster, the staff evacuates with the community and often never returns. The aftermaths of disasters in New Orleans LA and Galveston TX are excellent examples of what happens to healthcare organizations when they cease operations and attempt to rebuild after the disaster.
e. Quicker recovery is good business: The Disaster-Ready Health System will be able to recover much sooner than less prepared competing healthcare organizations. The disaster-ready organization fully understands the steps it needs to take in order to bolster its defenses against disasters and to continue to serve its community during and after a disaster.
f. Patients will trust a disaster-ready healthcare organization over a less dependable one: The CEO knows full well that he/she is a Community Steward for Healthcare Services and must be worthy of the community’s trust. Continuing to serve the community during and after a disaster can only be a positive thing…it can represent a critical competitive advantage.
2. OK, now the negative side of this argument for the less altruistic and those overly-optimistic CEOs who are certain a disaster will not happen to them. These are not bad people and these days keeping the doors open, the lights on and the staff paid, are challenge enough. Still, the consequences of being unprepared can have very dire career consequences for a CEO.
a. Future employment. Consider what the resume of the CEO will look like to future employers when the last Health System he/she led was decimated by a disaster.
b. Insurability. Healthcare insurance companies may take a second look when they discover they are insuring an organization whose CEO’s last healthcare organization failed under the weight of a disaster-especially if mitigation steps could have prevented the failure.
c. CEO-Board of Directors Relations. Imagine the Board of Directors’ reaction to an incoming CEO who let down his/her former Board of Directors by failing to take steps to address vulnerabilities which proved fatal to the facility and thus, the organization.
d. Citizen-Choice. Consider a community which finds itself with a choice between a Disaster-Ready CEO across town and the new CEO arriving from a health system that left his/her community without healthcare.
3. While I am all for using the positive approach in #1 above, it may be time to include both sets of consequences on the tables of Healthcare Organization Board Rooms across America.
Postscript: I once heard a man responsible for Readiness commenting on the consequences of a potential disaster. He said “The worst thing that can happen to me after a disaster is that I’m forced to retire.” I wish I was fast enough on my feet to say to that guy “No, that is not the worst thing that can happen to you….the worst thing that can happen to you is you go through the rest of your life knowing that your inaction and poor stewardship caused many deaths and untold suffering in the community that trusted you to care for its people.”
Being accountable for the community’s healthcare is good stewardship and good business.
[May 5 2009]
Good Morning: After recently reading and
watching the urgent stories about the Swine Flu, I couldn't help but wonder
how long it would take before we reverted to complacency. For years now, I
have been advocating for a calm, resolute culture of preparedness. Instead,
I have been seeing what I refer to as the PowerGlide of Public sentiment.
For those of you too young to remember, many Chevrolet automobiles in the
60's had a PowerGlide transmission. Low gear and high gear...that's all
there was..... two gears. In the last 8 years, we as a society, have had
only two collective mental gears....complacency and hysteria.
[Jan 27 2009]
This is an interim “After
Action” report on a disaster. What separates it from other reports is that
this Lessons Learned report can be studied before the event actually
takes place. There may be time for Congressional Commissions to not only
assign blame for a lack of Readiness after the fact (as they tend to do),
but perhaps appoint personnel to the appropriate agencies capable of
learning these lessons and putting real systems in place before the
Pandemic. It is the hope of this writer that instead of simply assigning
blame and writing reports (as most After Action review committees do), the
Congress might actually proactively write language into laws that demands
operational systems and not just the kind of information papers that
currently serve as “readiness.”
(1) Religious and charitable
organizations that will do much to bring America back to normalcy.
(2) Bandwidth for the increase
in communication requirements for any disaster
(3) Healthcare. Private Sector
or not, these are the bastions of America’s health in a disaster or Public
Health catastrophe. Build a Public-Private enduring relationship with
every American hospital, nursing home, medical center, specialty center,
community center etc., because in a disaster, they are all we have….and
federally fund disaster-related hospital expansion programs.
(4) Purchase a minimum 1,000
portable rigid or semi-rigid walled healthcare structures, 200 beds each,
with radiology and operating capability for long term use during any
disaster that destroys American communities healthcare infrastructure.
(5) Build a logistical support
system with civilian and military transportation assets sufficient to
re-supply every healthcare entity in America during disasters.
(6) Assign Public Health
Agencies a “hands-on care mission” for relieving the enormous stress
hospitals, nursing homes and medical centers will experience during a
pandemic. Provide funding not influenced by the “partisan dabbling” we have
seen in our past.
[Jan 5 2009]
I have been involved in community preparedness all of my adult life and have had the good fortune to work with some of the best folks in the Emergency Management field. When I read some of the conversations on this IAEM List, I thought I’d comment on the types of personal qualities that promote and foster a “Culture of Preparedness” in jurisdictions and communities. For readers who like the bottom line up front, I’ll provide it here.
If you are working for an elected official who is not committed, do whatever you can to help this person become a real Community Preparedness leader. It will not be easy to foster this change, but try to exhaust all possible strategies within your scope.
If you can’t help the elected official, it may be time to find a community whose elected official wants to be prepared and elected leaders who will support you. If you remain in a community and just go with the flow so to speak, you are truly a part of the problem.
Listed below are some traits that are absolutely necessary in Emergency Management leaders at all levels of government.
A Visionary: I think it was Walt Disney who said “If you can dream it, you can do it.” In our context, if the Emergency Manager does not have a clear vision of how his/her community must plan, train, test, learn and manage future disasters, he or she cannot lead their communities toward a Culture of Preparedness. The old mentality “we can all reach consensus and come together as involved stakeholders” sounds great and utopian but is a bunch of bunk. Someone needs to see the Big Picture, and have the requisite zeal for achieving the results of that Big Picture… and that person is the Emergency Manager at the local, state and federal level. True, the Emergency Manager can only be effective if the elected officials are truly committed to Preparedness, but the Emergency Manager is definitely the right person to articulate the vision of real community Preparedness.
A Leader: The National Response Framework (NRF) is useful in that it outlines very important concepts such as NIMS, an integrated Incident Command System where all stakeholders are a part of the total response. What the NRF is no good at providing is a no-nonsense “who does what for whom…and when” delineation of responsibilities. It seems that in America today, we don’t want to be demanding of others and we absolutely hate failure, so we engineer systems that can’t fail. Of course these “wiggle plans” can’t succeed either as we saw in recent disasters including hurricanes Katrina and Ike. New Orleans and Galveston Island are still living with limited or no Healthcare and Public Health infrastructure.
The Leader at the city and state levels of government needs to publish a clear and concise list of “measurable responsibilities” for the individual, local organizations (for-profit and non-profit), Non-Governmental Organizations, local governments and state governments. The plan needs to be clearly articulated using every possible media format and it must be signed by every stakeholder organization. We have seen all of the advertising on what we need to do to become “Digital TV Ready” on terrestrial, cable and satellite TV channels. Where are the 30 second spots on “what I need to do to become prepared” for the types of disasters listed in the jurisdiction’s Hazard Vulnerability Assessment (HVA)? Are we more concerned with getting “American Idol” than we are at getting prepared?.....apparently so.
When I start seeing public service announcements (or paid spots) on TV informing me of the types of events for which I need to prepare and what I need to do and have available in my home, I’ll know we are headed down the right path to Preparedness. Public Information is a mandatory part of developing a Culture of Preparedness.”
If you need to pay Risk Communicators to effectively send the message, pay them. If you need to pay radio and TV stations to run the ads, pay for them. If your elected officials will not support Community Preparedness, no matter your efforts to advance this, perhaps it is time to dust off your resume. There are many communities that with committed leadership truly want to become prepared…. find them.
A Good Steward: Every Emergency Manager in the United States is a “steward” of our tax dollars in the area of Emergency Management and Preparedness. I shudder when I hear Federal officials say the words “Use or it lose it” when applied to appropriated monies. If ever there was a verbal mandate for waste, fraud and abuse, this is it. No activities, projects or programs should be funded without clear plans, desired outcomes and measurements. Measure fearlessly! If you aren’t failing in some areas, your community is not discovering ways to do things better and recover sooner.
All available funding should support the Preparedness vision mentioned above and not personal wishes. The “Good Steward” buys Preparedness and not preference. There is no “what’s in this for me?” question in Good Stewardship. I happened upon the test for stewardship when I was in charge of medical war reserves in Europe. For just one item, (nerve gas antidote) I could either spend $10 Million on Mark1 Autoinjectors which were expiring (there is no normal use for Mark1 Autoinjectors and thus no stock rotation opportunity), or hope that the FDA would extend the shelf life on over a million units of expiring Autoinjectors. If I purchased new product and the FDA approved the shelf life extension, I’d have $10 Million in excess Mark1 kits…a very bad place to be when the General Accountability Office visits …and it will. On the other hand, if a war broke out and I elected not to replace the expiring Autoinjectors, hoping for that shelf life extension, I’d be in the position of issuing expired antidote Autoinjectors. I decided I’d rather explain to the GAO and to Congress my rational for replacing the antidote, than I would try to justify to parents and loved ones of Servicemen and woman why their loved ones had to use expired antidotes. I did the right thing and was prepared to defend my stewardship of taxpayer’s money. As it turned out, the 1991 Gulf War broke out. We had the required on hand assets of serviceable Mark1 kits and we had made the right decision.
A Teacher. As every teacher knows, helping others learn is a real challenge, but it definitely has its rewards. The Emergency Manager is the expert in all aspects of Emergency Management and that knowledge should be shared with all stakeholders and the next generation of emergency managers in the agency. It is hard work meeting with groups of elected officials, other agencies, elected officials, healthcare executives, public health officers, non-governmental organizations and civic groups. The fact is, we need the entire community’s participation and commitment in developing a Culture of Preparedness. On top of that, it takes stamina to keep the commitment to Preparedness alive and vibrant in the community. We all want to get “comfortable” in our daily lives and in our normal jobs. It is the Emergency Manager, who as the teacher and mentor keeps the Culture of Preparedness alive and young in our communities.
It’s a tough job and at times a thankless one. In that 1991Gulf War, I certainly was concerned that there would be casualties and fatalities on both sides. The one thing that I did not worry about was our ability to medically support our troops. I can’t even imagine the horror, shame and sadness I would have felt if I had made decisions based on the safe thing to do for me in the months and years leading up to the war. Emergency Managers will never feel good about a disaster that befalls their community. What can happen though is that each Emergency Manager as a visionary, a leader, a good steward and a teacher can attack future disasters knowing that he or she did the right thing and pulled out all the stops to assist their community achieve a real Culture of Preparedness.
[Jan 3 2009]
I am finalizing a paper I hope to have published in "Big Medicine" this weekend or early next week. I hope the article will in some way contribute to this vital discussion. In some way, we all know that Emergency Managers and elected leaders at the local, state and federal levels truly understand the challenges associated with creating a "Community Culture of Preparedness." To me it is a very clear description of the threats and the actions which must be accomplished to manage the consequences of those threats if deterrence fails.
A sober, very calm treatment of Emergency Management stimulates the will of the people to be prepared for what all Americans know will be future natural, man-made and public health disasters. Americans just don't like to think about unpleasant events. The Emergency Manager along with effective Public Relations folks can help with that issue and help us deal in a meaningful way with the types of disasters we will confront in the future.
The key to stimulating the will of the people is good Risk Communication, an established discipline which effectively communicates risk without scaring the people to death. Sadly, there are some in Government who feel in their heart of hearts that Americans can't handle the truth. This attitude must be combated vigorously at every level of government....and the Emergency Manager needs to take the lead in this charge.
Americans deserve to be told the threats that their communities and Nation face....AND...the personal measures each American is responsible for taking to mitigate against those threats. Americans also need to know what they can expect from each level of government AND when the prescribed relief will arrive.
Folks, the time for grandiose non-descriptive, feel-good plans are over. Words like should, could, and (my favorite) "May" need to be stricken from our EM dictionaries. We need to replace these wiggle words with "WILL" and make it happen. We need to be very descriptive and prescriptive but using a servant tone in all our plans. If a citizen neglects to do what he/she was told was in their area of responsibility, they must know that they dropped the ball and not FEMA or President Bush or their governor or mayor....they didn't do what they were supposed to do...period. At the same time, they must also understand that we care for them and that of course we will do whatever we can do to help.
The bottom line is we need to communicate each level of responsibility and couple this with the goods and services that each American must provide for themselves as well as those resources Americans can depend on at a timeframe certain. This means that unmanaged expectations like we continuously see in hurricanes must come to a screeching halt. I never worked for FEMA but I have served FEMA as a contractor and I can tell you that FEMA "does things", "provides things", "helps folks recover" and "cares about Americans." Lets get off FEMA's case until we all get out respective acts together.
The survival of America during very large or catastrophic events like a Pandemic, a nuclear detonation or a widespread attack on the Homeland demand a cogent set of plans that are easy to understand and that lay out responsibilities at each strata of American society. WE also need to fearlessly test plans, allow failures (almost no simulations) learn from failures, take aggressive actions to fix the failure points and constantly look for ways to do things better, faster and recover sooner. Political Correctness needs to be a show on TV and not a part of the EM Community.
Let the leaders lead and let the followers follow. Everyone else need only to listen to the directions of the Emergency Management Community, do what is expected on their part and demand that their elected officials and their Emergency Management Agency spell out what will be available, when it will arrive and for how long these local, state and federal goods and services will be available. "Leadership...its always about leadership! "
[Oct 24 2008]
It seems everywhere we look today; there is information on how we as a society can prepare for a new strain of avian influenza capable of ravishing our communities.
Health Officers can significantly control access into and
out of their jurisdiction, it is hoped that the disease can
be encircled, isolated and contained within the quarantined
jurisdiction. In that way, the virus cannot perpetuate
itself as efficiently and as a result, it dies out.
Quarantine has been recognized for centuries as an effective
tool for controlling contagion, it has a number of dire
One of the
consequences is the accumulation of normal and
pandemic-associated untreated healthcare regulated medical
hospitals that use “off-site” transportation and treatment
services for medical waste going to rid themselves of their
The fact is,
“they have a problem.”
The last thing Public Health officials need are mountains of untreated medical waste piling up in hospital parking lots throughout their jurisdiction.
Of course the
issue here is that most hospital incinerators were
decommissioned and removed after passage of Clean Air Act of
1970 and the Resource Conservation and Recovery Act (RCRA)
of 1976. It became clear that there was no come-back likely
for onsite incineration. There is a solution to this problem
and it is “Back to the Future” in effect.
heydays of the incinerator, alternative “on-site RMW
treatment technology has advanced to the point where it is
the most socially-responsible, environmentally friendly and
cost effective method to treat medical waste at the
healthcare facility level.
healthcare professionals believe that once their medical
waste is handed off to a transporter, the healthcare
organization is “off the liability hook.” Not so according
medical waste is the responsibility of the generator (in
this case the healthcare organization) from the “cradle to
the grave”, or in other words until the medical waste is
necessity truly is the mother of invention. As Public Health
Officers continue to work on Pandemic Preparedness, many
will examine the possibility of using Federal Grant dollars
to enhance America’s Pandemic preparedness with on-site
medical waste treatment technology.
On-site RMW treatment technology reaps immediate benefits by reducing the amount of RMW being transported through American communities and across our roads and Interstate highways. It also protects healthcare workers and conserves valuable landfill resources.
[Sep 8 2008]
With Hurricane Ike in the news, I thought I'd share an article I wrote some time ago on how healthcare organizations can perform a quality “gap analysis” to identify unmet requirements and then to work on narrowing the gap between what is required versus what is on-hand and available through local suppliers to build a robust and resilient healthcare organization. Also, since The Joint Commission (TJC) has significantly broadened and emphasized healthcare Emergency Management standards for 2009, this article may be timely for those preparing for TJC surveys.
Everywhere we look these days, there seems to be guidance suggesting that healthcare organizations should perform a complete “Gap Analysis” as part of their Emergency Management Program (EMP). What seems to be lacking, is a recommended process to perform the “Healthcare Gap Analysis.” This process is also relevant to Public Health Departments. The jurisdiction’s Emergency Manager’s participation and leadership in Gap Analysis is vital to this process.
There are four major components to a thorough Gap Analysis: (1) Identification of planning scenarios along with the number of anticipated casualties for each planning scenario; (2) Requirements development; (3) A listing of current resources and capabilities; and (4) Identification and forwarding to the next higher support agency, the gap between current resources and capabilities and the total requirements needed for each planning scenario. The following is an attempt to clarify the various components of a complete Gap Analysis process.
1. The Planning Scenarios and the estimated number of casualties (live patients). What types of emergencies are likely to befall a jurisdiction and how many casualties will likely be generated by each planning scenario? To get to these data, healthcare planners must consult with the jurisdiction’s emergency management agency. The jurisdiction’s Director of the Emergency Management Agency (EMA) performs Hazard Vulnerability Assessments (HVA) for the entire community. Based on these HVAs, healthcare planners can obtain a number of planning scenarios which the jurisdiction could reasonably face. While healthcare planners may consider many planning scenarios, for this discussion we will base the Gap Analysis on the top 3 planning scenarios provided by the EMA. For each planning scenario, the healthcare planner must also obtain estimates of the number of patients that will be generated. The EMA can often estimate the numbers of casualties (patients) and fatalities (dead), as well as the categories of injuries (such as burns, blunt force trauma and blast) for each planning scenario based on past disasters - such as the London bombings or the Tokyo subway Saran attack. The local or state Public Health Officer is the source for estimating the numbers of infected patients generated by events such as a SARS outbreak or a Pandemic Influenza. HHS and Public Health sources such as the Centers for Disease Control and Prevention may also provide estimated numbers of infected persons based on a jurisdiction’s population and may also offer advice as to the likely percentages of patients who will require hospitalization. The Agency for Healthcare Research and Quality (AHRQ) also has a variety of very helpful tools and documents to estimate casualties from a number of disaster events.
2. Requirements Development. Another way of phrasing this component is: “what resources will be needed to treat the numbers and categories of patients injured or infected as a result of each of the top 3 planning scenarios?” The requirements component of Gap Analysis is the process where healthcare organizations identify every resource that will be required to effectively treat the estimated numbers and categories of patients resulting from scenarios identified in the community HVA. Hospital requirements in facilities include: beds, staff, medical supplies and equipment (such as ventilators, specialty beds and surgical equipment), transportation, food, water, generators/emergency power capacity, fuel, medical waste treatment equipment or service, or any other resource required to treat the numbers of estimated casualties for each of the top 3 planning scenarios. The requirements or “needs” of the organization must not be influenced by what resources the hospital has on hand or can readily purchase from its suppliers. Facility “requirements” and “available assets” must remain separate. The reason why the requirements component must be separated from available resources will be discussed in items #3 and #4, below. While the requirements development portion of a Gap Analysis is not a difficult process, it is tedious and time consuming. Perhaps that is why the requirements process is often the most poorly defined component of the Gap Analysis.
3. Current Resources and Capabilities. This component of the Gap Analysis process depicts the entirety of the resources the healthcare organization has at its disposal against the number and categories of patients it needs to treat. Many healthcare planners feel that they must somehow obtain the additional resources needed to manage a given scenario. The reality is that the National Response Framework (NRF) anticipated that requirements will far exceed local and even state/territory resources. The Emergency Support Function (ESF) organization at the Federal level responsible for providing Public Health and Medical Services sustainment support is the Department of Health and Human Services (HHS) as the ESF-8 agency. HHS is tasked to provide the difference between city and state/territory available resources and capabilities and the total requirements and capabilities needed to medically manage large scale events. It is therefore imperative that local and state/territorial resources and current capabilities and the “Gap that exists between “Requirements and On-Hand assets” be expressed accurately. Only then can the HHS (and other Emergency Support Functions) properly plan, program and budget for the “Gap” that exists in jurisdictions across America.
4. The Gap Analysis and what to do with it. The “resource and capability gaps” for each planning scenario is the difference between available resources and capabilities and the total requirements. The National Response Framework requires that local healthcare organizations pass on requirements exceeding available resources to the local Emergency Management Agency (EMA). The unmet requirements which cannot be met at the local jurisdictional level must then be forwarded to the state/territory or Tribe EMA. Finally, unmet state/territory/Tribe unmet requirements for resources and capabilities will be forwarded up the chain to the Federal agency responsible for providing the individual Emergency Support Functions (ESF). In the case of Public Health and Medical Services, the Federal support function is ESF-8, and is provided by the Department of Health and Human Services (HHS) and the various support agencies.
By well-defined Gap Analyses from jurisdictions across America, HHS can then analyze, plan, program, budget, procure and pre-position additional resources and capabilities needed to close Gaps and sustain and fortify America’s Public Health agencies and the private healthcare industry during future emergencies and disasters requiring Federal support.
If the Gap Analyses at the hospital and health system are properly depicted and routed through the local and state Emergency Management Agencies, Federal Emergency Support Functional agencies can program for the entire array of “unmet requirements” including mobile medical units, as well as a full complement of staffing, medical and non-medical supplies, equipment and services required to support state/territory and local governments during future disasters and public health emergencies. For example, if the Gap Analysis discovers a hospital’s back-up power generator is insufficient for “long run power generation” (sometimes called an intermittent short duration back up generator), perhaps in the earliest stages of a disaster, the State EMA could immediately deploy long-run power production back-up generators to those hospitals. An even better solution would be for Emergency Managers to proactively work these challenges with healthcare executives and share DHS/FEMA grant dollars to close back-up power capability gaps. Compared to evacuating, tracking patients to healthcare organizations outside the affected communities, the proper power production generator, connected to all vital hospital utilities (including HVAC) is a real bargain.
It is imperative that healthcare, public health and jurisdictional emergency managers work extraordinarily closely in identification of all gaps in resources and capabilities and forward the appropriate unmet requirement gaps up the NRF support chain in order to ensure the healthcare and public health needs of communities are met during future man-made and natural disasters. If quality Gap Analyses are conducted and acted upon proactively, we may see healthcare organizations and public health departments performing brilliantly in future disasters, saving and protecting the lives of those in the communities these organizations serve.
[June 28 08]
I wish we would stop studying
our healthcare industry's inability to respond adequately to
a large scale disaster. It's really quite simple....the
healthcare industry has been in crisis for over 20 years and
many (if not most) ER's are on "Divert Status" during
weekends and normal spikes in demand for health care
services. The American Healthcare Industry cannot respond
effectively and won't be able to respond effectively to any
Large-Scale disaster. The reason: The American Healthcare
Industry is not funded to surge to manage large-scale
disasters. Man, was that a thrifty Readiness Assessment.
In the case of Healthcare and
Public Health Readiness, it seems Congress arbitrarily sends
an allocation to HHS and says "Do things with this money." I
was an HHS/HRSA employee and I could never understand why we
didn't send up to Congress a Requirements Statement along
with the line item of each requirement. I know the people
are great, but I still don't get it.
[June 9 2008]
I recently took a breather from Healthcare
Readiness and returned to Healthcare Administration to recharge my spirit
and to get back to doing real healthcare operations. I was really burned out
from reading and writing scholarly articles on Readiness and wondering when,
or if indeed if I’d ever get to actually do things again. OK, my articles
weren’t scholarly at all, but I tried. Being a high energy person who loves
serving people, my healthcare hiatus was just what the doctor ordered. In my
case, the doctor was my wife and she also ordered me home…I can’t understand
why. One of the things I took away from my recent “on-the ground” healthcare
experience was just how demanding Healthcare leadership is in an environment
of dwindling resources. Now that I’m back, I thought I’d try to write an
article on how Emergency Managers and Healthcare leaders can work together
to offer their communities the best chance of surviving future disasters.
[Jan 7 2008]
As part of the disaster preparedness planning process, many emergency managers, especially in large metropolitan areas, are facing the realities of a possible London or Madrid-style mass casualty scenario. Even more disturbing, emergency managers in financial and political centers which are likely considered “high-value” targets by terrorists are facing the prospect of thousands or tens of thousands of casualties and evacuees associated with a nuclear attack. Overwhelming numbers of casualties in a truly catastrophic event can be managed by looking at healthcare models affectively used on the battlefield.
This writer was fortunate enough to be a part of a 1980 US Air Force initiative which adopted many of the lessons learned by the Israeli Defense Forces in battlefield medicine, particularly during the Yom Kippur war in 1973. This system, called the 4-Echelon Battle Casualty Management System, can now be adopted by emergency planners and managers for managing mass casualty scenarios in civilian settings.
Introduction to the 4-Echelon Mass Casualty Management System.
Battlefield casualty management experience has resulted in advanced and effective rescue, resuscitation, stabilization, definitive treatment and rehabilitation of soldiers ever since World War II. The use of the helicopter as an air ambulance greatly improved the survival rates of soldiers wounded in combat in Korea and Vietnam and in all conflicts since. Many trauma procedures develop in combat medicine have been applied with great success to our civilian trauma systems. With the ever-present threat of terrorist attacks using biological, chemical, radiological/nuclear and explosive agents or devices, the time may be right for jurisdictions and their civilian healthcare systems to implement a combat proven system for mass casualties called the 4-Echelon Mass Casualty Management System.
For more than 10 years, Public Health agencies at all levels of government have been ramping up capabilities for early detection and responses to biological warfare agents and disease outbreaks. Public Health planners have also developed strategies for providing rapid post exposure medications and vaccinations to millions of people affected by these man-made and naturally occurring events. The time is right to forge strong relationships between the Emergency Management community, Public Health agencies and Private Sector healthcare organizations in planning for large scale disaster or emergency events..
What is the 4-Echelon Mass Casualty Management System? The 4-Echelon Mass Casualty Management System is a highly effective and efficient system of managing very large numbers of casualties throughout a disaster and until local healthcare organizations recover and can resume normal operations.
The 1st Echelon of care is provided by first responders and consists of immediate lifesaving procedures and the rapid transport of the living to a 2nd Echelon facility.
A 2nd Echelon facility may be a trauma center or an emergency department. The 2nd Echelon is essential in making the most of the patient’s “Golden Hour.” By providing immediate care and by dramatically increasing the casualty throughput to 3rd and 4th Echelons, the 2nd Echelon care providers prevent or reduce the patient gridlock associated with a disaster and thus, optimize the saving of lives. 2nd Echelon care is designed only to save lives and stabilize patients and not to provide definitive care. Employing the latest advances in trauma care, 2nd Echelon care includes procedures for saving life and limb and stabilizing patients. Typically at the 2nd Echelon, providers ventilate patients if necessary, control bleeding, infuse blood products and expanders and amputate limbs as required. Once stabilized, patients are quickly transported to the 3rd Echelon of care for definitive treatment.
The 3rd Echelon of disaster healthcare is typically a hospital or medical center away from the immediate disaster location. In the early stages of a disaster, a hospital or medical center may provide both 2-E and 3-E care. It is likely that a hospital’s 3-E capacity will almost immediately be reached and the facility will revert to 2-E care only. 3rd Echelon facilities may be within a jurisdiction or may include hospitals in several jurisdictions or even national regions, depending on the number of casualties and the care requirements. Definitive care is provided at all 3rd Echelon facilities, but specialized care such as burn centers may also be provided in a 3rd Echelon facility. This includes a full complement of surgery specialties, diagnostics and follow-on care for about 7 days. Patients who cannot be discharged within a week are normally candidates for 4th Echelon care.
The 4th Echelon may include specialty centers or rehabilitation hospitals capable of providing long term ventilation care, psychiatric care, burn or wound care and rehabilitation or specialization in physical therapy or orthopedic care including providing prosthetic devices and associated therapies.
Depending on the location and scope of the disaster, a particular hospital may function as a 2nd, 3rd and 4th Echelon facility. When close to the disaster location, a hospital may have to function only as a 2nd Echelon facility, transporting all stabilized patients to 3rd and 4th Echelon facilities further away from the disaster location. By so doing, the hospital serving as a 2nd Echelon hospital may be able to accept more patients in need of stabilization than it could as a multiple-Echelon facility. In another disaster scenario further away, this same hospital could be functioning as a 3rd or 4th Echelon facility, providing definitive and/or specialty care to stabilized patients.
What is the role of Healthcare Organizations as part of a 4-Echelon Mass Casualty Management System? Most medical centers and many hospitals operate as full 4-Echelon capabilities during normal everyday operations. During a disaster, Healthcare organizations will periodically self-declare their capabilities to the Emergency Operations Center (EOC) in terms of the Echelon of care they can provide in a fluid environment. Depending on the size and scope of a Mass Casualty event, a hospital may eliminate the 4th-Echelon immediately and declare itself as 2nd and 3rd Echelon capable to the medical representative in the Emergency Operations Center. At that point, the EMA would reach out to adjacent jurisdictions to activate their EOC (s) and to provide a list of healthcare organizations capable of providing 4th Echelon care. At some point in disaster operations, an individual healthcare facility may declare itself limited to 2nd Echelon care only, thus requiring outside healthcare support at both 3rd and 4th Echelons. In fact, in some circumstances, a healthcare organization may reach full capacity and be incapable of accepting any additional patients. In other cases healthcare organizations may be damaged in the disaster and may need to report to the EOC that all patients must be evacuated and transported to healthcare organizations outside the affected area. In any case, healthcare organizations must be able to efficiently communicate their capabilities with the jurisdiction’s EOC throughout the disaster.
How can 4-E work in a competitive Healthcare Marketplace? A traditional model of disaster healthcare seems to dictate that healthcare organizations provide the full continuum of care to all patients presenting for care. Competition would seem to dictate that hospitals or medical centers expand (surge) their services until their individual capacity and capabilities are reached. Why then would hospitals want to self-declare themselves as a 2nd Echelon facility and request rapid transport of stabilized patients to healthcare organizations outside of their service area? The answer lies in continuity of operations. Hospitals in the affected area need to recover and resume normal healthcare services as soon as possible after a disaster. By serving as a 2nd Echelon facility and rapidly transferring patients to 3rd and 4th Echelon facilities outside the affected area, hospitals and medical centers in the affected area can conserve staffing and material resources and thus, can more rapidly recover after the disaster event.
This definitely requires a paradigm shift, but experience shows that after a disaster, healthcare providers need decompression time. If the staff is exhausted, who will provide healthcare services immediately following a disaster? Likewise, medical supplies are consumed at an enormous rate during a disaster. Equipment used during a disaster needs to be disinfected and inspected prior to being returned to normal service. If the support services personnel are exhausted, who is going to disinfect hospital areas and the equipment and how long will the hospital be closed after a disaster? Heart attacks and strokes will still occur, babies will be born and the population in general will need care immediately after a disaster.
Finally but importantly, disaster operations can and do strain healthcare financial resources to the breaking point. The last thing that any community needs after a disaster is a number of bankrupt hospitals or medical centers. Civilian healthcare organizations cannot issue continuing resolutions in order to make payroll or pay suppliers during and after a disaster. Federal and State payers as well as private insurance companies must develop and publish simplified health care claim procedures for use during declared emergencies. These simplified claim procedures will sustain healthcare organizations and their services during and after a disaster and can help ensure that healthcare services are available after the disaster. Perhaps, simplified financial procedures can be tied to services rendered at each Echelon of care.
Adopting the 4-Echelon Mass Casualty Management System. The first step is the adoption of the 4-Echelon Mass Casualty Management System by a state or territory EMA and the Healthcare organizations within the jurisdiction. Once proven in a single state, the 4-Echelon System may be adopted throughout a federal region or multiple regions. In time, the 4-Echelon System can be adopted Nationwide. The 4-Echelon System will fit seamlessly into the National Disaster Medical System (NDMS), since NDMS healthcare facilities were the planned 4th Echelon of care for service members returning from either the European or Pacific theaters of operations, had the Cold War turned hot. Although the 4-Echelon System never needed to be fully implemented on the American battlefield, it may be the right civilian disaster healthcare solution at precisely the right time.
[Nov 20 07]
I recently read Hal Newman’s article
“Reflections on Life, Death and EMS.”
I want to share an article I wrote for the
Association for Healthcare Resource and Materials Management (AHRMM) with
the readers of Big Medicine. There is absolutely no question in my mind that
emergency managers possesses experience and training that is priceless to
both Healthcare and Public Health leaders at all levels of government. The
ongoing emergency response to California’s wildfires is a vivid example of
the type of integrated response that jurisdictions across America should
emulate. While the economic and personal losses are horrible, we can only
imagine the losses in human lives if California’s emergency management
system was less well refined.
[Oct 26 07]
[Oct 8 07]
I thought I'd add my two cents on shortfalls
in America's preparedness to deal with the Pandemic that experts agree is
coming sooner or later. I will continue to advocate building Federal Reserve
Inventories (FRI) to bolster our food, chronic illness medicines, and
medical supplies and equipment supply chains during National catastrophes
like a Pandemic or a nuclear attack on a large American population center.
FRI will keep the supplies coming during future crises and will keep America
from developing a "Culture of Scarcity" which could be devastating to our
people and our economy. I though I'd share some experience that leads me to
worry about our societal expectations regarding necessities of life in a
National crisis. Since product rationing during World War II, we have never
had to endure severe and long lasting outages of products or services that
we have come to expect in modern day America. That in itself can be a huge
Can we start now?
Have you been loosing sleep since reading report after report on the inadequacies of shelters to care for persons with special needs during the 2005 Hurricane season? If so, you are not alone. You may take comfort in knowing that you are among the distinguished company of many good and decent Emergency Managers across America. During hurricane Katrina, I found myself asking “How can we call ourselves a great and compassionate Nation when we fail to care for the most vulnerable among us in the worst of times?” The answer I arrived at was “we can’t.”
For the general population, we pretty much have the needed food, water, clothing and shelter items down pat. However, what about the growing ranks of citizens with special needs, now estimated at one fifth of America’s population? The challenges must be significant since we often can’t even agree on the definition of special needs populations.
Why don’t we forget about defining specific groups of special needs folks and let them self-identify? Instead, perhaps we should define specialty sheltering items and services available, and leave it at that. We might want to just say, “Specific shelter locations for persons with special needs will be designated and advertised in regular communications with the general public and persons with disabilities advocacy groups. Special Needs shelters will be provisioned with the following: medical and non-medical supplies and equipment, pharmaceuticals, nutritional products, and personal assistants and interpreters (which may be required during sheltering events by non-English speaking persons or persons with chronic diseases or physical, emotional or psychiatric disabilities).”
While that statement is easy to reduce to writing, the processes needed to determine which items should be stocked, how many of each item to stock and how to conserve the community’s investment in inventory (by avoiding product expiration in storage), are not as easy. Recruiting sign language specialists, interpreters and medical assistants are also challenging tasks. Below are some suggestions which may be of value when planning special needs shelters:
Public service announcements are a great way to get information out during community or statewide exercises. In the PSA, consider specifying the types of services that will be provided in each special needs shelter and the personal items evacuees need to bring with them. Another way to reach persons with special needs during a disaster is through advocacy groups. Consider flyers, press releases and newsletters as good ways to publicize which shelters are designated to care for persons with special needs and the particular goods and services offered at each shelter location. Advocacy groups should be brought into exercise planning as well as designating shelter locations for persons with special needs. During exercises, your advocacy group partners can be invaluable in getting folks with special needs to the shelters providing the goods and services people require.
It may not be necessary to develop “qualifying criteria” for the shelter. In the end, if a person self-identifies that he or she has special needs during disaster sheltering operations, the shelter manager will have to take those special needs seriously with or without a special qualification. Some states are developing “registries” where persons with special needs can sign up in advance. Due to privacy concerns, each State and Territory public health department should have involved specialists in patient confidentiality and the requirements of various Federal regulations regarding privacy. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 has specific requirements regarding the privacy of a persons health records which may pertain to special needs shelters.
Special Needs persons, including folks with disabilities and the elderly, will need a host of support services. For example, in an evacuation, a person who was receiving wound care from home health professionals will need to know which shelter locations will be staffed and supplied to provide wound care. A person who uses diabetes supplies and insulin may not have sufficient supplies to endure a lengthy stay in an evacuation shelter.
Persons who rely on psychiatric medications did not receive adequate support during hurricanes Katrina and Rita according to the National Council on Disability (NCD). Their findings: “THE NEEDS OF PEOPLE WITH PSYCHIATRIC DISABILITIES DURING AND AFTER HURRICANES KATRINA AND RITA”: POSITION PAPER AND RECOMMENDATIONS; National Council on Disability, July 7th, 2006. Now I have read scathing indictments on Inspector General (IG) and the General Accountability Office (GAO) reports in the past, but nothing ever came close to the ones listed at: http://www.ncd.gov/newsroom/publications/2006/peopleneeds.htm To make matters worse, the NCD is a federal policy agency, and there is little to suggest that significant progress has been made across America since 2005 in sustaining persons with psychiatric disabilities.
4. Determine the specific supplies and equipment required by the special needs shelter.
We know there are literally hundreds of reports, papers, studies and all manner of well intentioned works in the Public Domain regarding the subject of caring for folks with special needs. I have been unable to find a single report or study that lists the processes that may help Emergency Managers decide what items to include, how to arrive a quantities of medical and non-medical supplies and equipment to manage and how to get the products and services to the right place at the right time. I thought I’d step out into the discussion and list some concrete steps that my be taken by Emergency Managers who want to make the 2005 Hurricane season a horrible but non-recurring nightmare.
ü Recruit a subject matter expert (SME) team consisting of healthcare specialists in Disabilities, Emergency Medicine, Geriatric care, Psychiatric care and long term patient care. Although nurse specialists will select most of the patient care items, it may be a good idea to recruit a physician as the SME team leader. Prepare for success by selecting a strong leader for your formulary and special needs development team. A pharmacist will be the SME member who will extremely helpful in the standardization and cross referencing of medications. The reality of life in a shelter operation will dictate a “lean formulary” and the pharmacist will be invaluable in areas of drug interactions as well as using standardized substitute drugs. A respiratory therapist and a dietician (for special feeding items) would also be good choices as team members.
Last but not least, recruit a healthcare purchasing agent or a materials manager as the person who will provide sources for the various products on your formulary listings. The SME team will need to concentrate on standardizing items in order to meet needs but keep the requirements lists manageable. The purchasing agent or healthcare materials manager can play a supporting role but you need a strong medical person as the formulary development leader, since many formulary choices will be difficult but essential.
ü Divide your formularies and services into categories, since this will make vendor selection and advocacy professional group reviewers tasks easier. Food and special feeding items, medical surgical supplies, medical equipment, pharmaceuticals, patient care and apparel and hygiene needs are some of the commodity categories SME teams will need to consider. Just some categories of needs and products include:
· Redundant notification systems to notify persons with disabilities that an emergency exists and all pertinent actions that need to be taken
· Special assistants for the blind.
· Special assistants for the deaf and hard of hearing including couriers for notification.
· General services shelter volunteers
ü Select distributors for materials. Most state and territorial Public Health agencies have separate vendors (often called prime vendors) for major product categories such as; vaccines, pharmaceuticals, medical supplies and medical equipment. When allowable, it’s a good idea to piggy back onto existing state contracts for special needs shelters instead of letting new contracts. This is because the shelter manager can leverage the jurisdictional purchasing power and often obtain existing jurisdictional contract pricing and terms. Since the Public Health agency is normally the provider of supplies and equipment for special needs shelters, the additional materials can be added to the existing contract by using a contract amendment. The public health purchasing agent can work with the state contracting officer on any contractual issues involving special needs shelter acquisitions, delivery and billing information. The key in this area like all other emergency management functions is advance work. Those Public Health agencies that wait to develop formularies and arrange contractual details until an actual disaster is underway will most likely be the ones calling FEMA immediately for help. Also, in large scale disasters, there may be system-wide supply and equipment shortages.
ü Recruit and train special services staff. Advocacy groups for persons with disabilities and other special needs people may be able to help the special needs shelter manager identify companies which provide services to persons with disabilities. Non-governmental organizations including the Red Cross, Salvation Army and Goodwill Inc. as well as faith-based congregations may be able to provide volunteers. Whether the persons who will staff the special needs shelters are paid or unpaid workers, the identification and training components must be accomplished beforehand in order to succeed.
3. Conclusion. The special needs of persons with disabilities and other vulnerable persons will exist whether or not State and Territorial Emergency Managers and Public Health Officers plan for the needs in advance. Advance planning will make a difficult situation manageable. The lack of advance planning will not only be a disgrace and will likely cause pain, suffering and perhaps deaths.
Throughout my career in healthcare, medical logistics and emergency management, I asked myself if my planning would be sufficient for my mother and sisters should they require sheltering in a disaster situation. In the end, persons with special needs are indeed our community family. Good enough doesn’t cut it for family and shouldn’t be “good enough” for our community members, especially the vulnerable. Planning for and submitting our requirements and the associated budgetary figures to the appropriate funding authority may not result in all requirements being funded. What it will do is demonstrate that you took the time to determine what is needed, you articulated the needs in writing to the funding authority and as funding was made available, you provided for the needs of our community, including our most vulnerable persons.
[Jul 31 07]
One of the many hats an Emergency
Manager must now wear is that of a trainer. Communities need
training and familiarity with procedures that work in every day life
as well as disasters. For years, we have had pretty much the same
scenario of actions following an incident: first response, triage,
on-scene stabilization and transportation of casualties to the
appropriate level of care. So a question may be: “What additional
steps can be taken by Emergency Managers to prepare the community
for the real thing?” One answer to that question is “Community
[Jun 30 07]
Sometimes I find myself fondly remembering the good old days when Community Emergency Management seemed to be a fairly straightforward function, but today things have definitely changed. There are now many more players with a role in emergency response which Emergency Managers must help integrate into their jurisdiction’s total disaster response effort.
If you have asked yourself “What can I do to assist Healthcare organizations and Public Health departments integrate into a jurisdiction wide All Hazards response team?” the answer is you can do a great deal.
I’m afraid what we have today is an old paradigm being applied to a new reality. First responders rescued casualties, provided emergency medical attention on the way to the hospital and handed off casualty care to the hospital. Hospitals had decent staffing levels and the medical materials to accept the additional casualties. The good old days are gone.
In 1974 when I first entered the field of Healthcare Disaster Preparedness nearly every hospital had a warehouse. Demand forecasting was an exciting future promise in Materials Management but was not to become a reality for another 10 years or so. Nearly every hospital and medical center had enough supplies to keep clinicians supplied for anywhere from 30 days to three months.
Healthcare staffing, including nurses, nurse assistants (I don’t remember certified nursing assistants back in those ancient times) and support personnel staffing levels, were much more generous in the good old days.
Today, healthcare staffing is extremely lean, and in many cases around America the medical profession is losing too many caring people who say that Healthcare has become much more about the bottom line than it is about care.
Today, managed care, reduced Medicare and Medicaid reimbursements accurate demand forecasting of medical products through computerization, and what has become known as “Healthcare Supply Chain Management” has changed Healthcare’s ability to manage a disaster-related surge in casualties dramatically. The financial pressures on Healthcare are immense and everything must be “optimized.”
In staffing, the questions starting back in the 80’s became, “what is the optimum nurse to patient ratio?” Can registered nurses become “care team leaders” and become more of a manager than a caregiver?
In Materials Management questions were asked “How can we optimize our inventories?” “How can we drive costs out of our purchasing plans?” How can we minimize our medical product inventories and the associated dollars tied up in inventory?
The bottom line question is “Aren’t these costs containment measures and a Just-in-Time” supply chain strategies a good thing?” The answer is:” As long as nothing unanticipated happens and if staffing levels reflect the true patient care acuity levels, it can be a good thing”. However, if something unanticipated happens…..lets say a disaster, healthcare can become almost instantly overwhelmed.
Will hospitals and medical centers close down and defend in place once patient capacity is reached?
What will Emergency Managers do with casualties when healthcare organizations reach full capacity and close their doors?
Perhaps better questions are, “What can Emergency Managers do in advance of the next disaster to help Healthcare and Public Health leaders in the community better plan for disasters?” and ”Is this mission impossible?
In the “Mission Impossible” series, the voice on the disintegrating tape recording said “your mission if you chose to accept it…” Well, here are a few suggestions that may be helpful to you, if you choose to take on the role as a true integrator and make yours a mission possible.
Emergency Managers understand resource management and conservation of critical assets in a disaster. You also know that you can’t expend all of the jurisdiction’s healthcare assets in disaster-care and not be able to treat the heart attack, stroke and trauma patients until after disaster recovery. You can help healthcare leaders by brainstorming ways to incorporate all community medical personnel including urgent care centers, private physician practices, all medical materials resources, all non-governmental organizations including faith based organizations into a “Community Healthcare Expansion and Sustainment System.” You understand that in a disaster, the hospital or medical center is the last bastion of defense in caring for the sick and wounded. You understand multiple levels of response in a disaster battle plan. Healthcare and Public Health leaders across America need your years of experience in building robust disaster response systems more now than ever before.
In addition, most Public Health agencies will appreciate being involved in the jurisdiction’s planning and your experience in managing disasters. As you present concepts of Emergency Management including how the Incident Command System works, the Public Health folks will want to do their part and will grow from the experience you offer. Then, Healthcare and Public Health entities may begin to work together while sitting at your table.
Let’s face it, the 1918 Pandemic was a long time ago and since then, Public Health Departments have concentrated on early detection, post exposure prophylactic treatment, immunization and mitigation measures like anti-viral medications. As you read your State or Territory’s Influenza Pandemic Plan, use a highlighter pen to mark up all the areas that address hands-on healthcare. Then see how many highlighted sentences and paragraphs you have. It is likely that providing healthcare to influenza patients receives very little coverage. The question that needs to be asked is where patients will go for treatment when hospitals reach capacity, exhaust staff or run out of supplies.
If you can implement just the five tips mentioned here, you will have not only done your job well, but you will have changed the entire culture of Integrated Emergency Management in your jurisdiction. Once you have all the stakeholders in the same room, facing the same scenarios and the associated casualty numbers, you should be well on your way to leading a true integrated community response.
There is no use in having a robust First Responder capability if the end result is hundreds or thousands of casualties being dropped off in hospital parking lots because the hospital’s capabilities have been exhausted. There is no use in developing fully compatible, redundant and highly survivable communications systems if the messages communicated during a disaster are nothing more than a litany of failures in law enforcement, healthcare, public health and municipal services. A jurisdiction must develop balanced system wide response capabilities if it is to have a successful disaster management system. The heavy lifting comes in when the Emergency Manager attempts to build leveled capabilities into the jurisdiction-wide integrated response systems. Grant proposals must depict activities in such a way as to demonstrate the interdependence of all jurisdictional disaster-related activities as an interrelated system which requires cross functional funding. The jurisdictions that can share grant funding as a community and not as a number of discreet interest groups will be the jurisdiction that provides outstanding disaster services to its citizens. The acid test of leadership and community cooperation will be evident on disaster day, or D-Day.
Develop all the requirements and the line item by line item costs that are needed to sustain persons with disabilities and special needs at home, during evacuations and in evacuation shelters or healthcare centers. Then move the requirements and cost data upward as called for in the National Response Plan. The Emergency Manager can link the requirements to NIMS resource typing and can express how the requirements will be necessary in order to attain Target Capabilities and Universal Tasks. If the Emergency Manager cannot do this, it is extremely unlikely that anyone else in the jurisdiction can.
Finally I’d like to share a thought I had many times when I was stationed in the Republic of Turkey. As the Regional Chief of Medical Logistics Management and being at the geographical and literal end of the Supply Pipeline, almost every day presented challenges that I never had to deal with before.To get though those days that stripped me of my boyish good looks I would say to myself… “You may not be all that good, but you are all the folks have and you have to get this done.” I hope each Emergency Manager reflects on that quote as they plan for communication, evacuation, and sustainment of persons with disabilities and special needs at home, in shelters or in care facilities during disasters.
The fact is you are that good, persons with disabilities and special needs depend on you and you have to get this done.
[May 11 07]
There is a lack of communication in America regarding Pandemic Influenza planning and resourcing, and it must stop immediately. The Federal leadership is putting out a loud and clear message that, in a Pandemic, the States and Territories will be pretty much be going it alone. That sounds great since the CDC grant programs are pouring money into State Public Health Departments so they can do whatever they need to do to pretty much “Stand Alone” during a Pandemic. So what’s wrong with the plan? Plenty!
The major problem that nobody wants to talk about is that America is unwilling or unable to address where sick Americans will get care during a Pandemic that Federal Agencies are saying will occur.
The Public Health Community is taking a three-pronged approach to managing a Pandemic.
The Issue: It is estimated by Federal Officials that about 45 Million Americans will need some form of professional medical care.
Home Care. None of the above strategies discuss where the sick Americans can go to get the definitive care that Federal officials are saying they will need. Even worse, the other 45 million, give or take a few million, Americans are going to need to care for themselves or have family take care of them at home. Did anyone tell the makers of Robbitusin, NyQuil, VapoRub, Aspirin, Tylenol and the other manufacturers of over the counter (OTC) medications and other cold and flu home care supplies and equipment to expect a bit of a spike in demand for…let’s say a year or so? Do the drug store chains know anything about this? Do we think that when the drug store chains and supermarkets run out of OTC medications the folks who may have been able to stay home will now have to go to the ER? Pretty good bet isn’t it.
Hospital Care. Every time we open a newspaper or a magazine, we read that the American Healthcare System is in a state of crisis. With financial pressures from managed costs (oops! that’s managed care isn’t it), reduced Medicare and Medicaid funds, and an increased Baby Boomer population, our hospitals and medical centers have been at near capacity for some time now. Emergency room visits are up in many, if not most, areas of America. But as the saying goes; “You ain’t seen nothing yet.” In a Pandemic, when the shelves of OTC and home care products are empty, every ER in the country will be inundated. Or will they too run out of supplies?
Under the best of healthcare surge plans, we might be able to take on one million very sick patients that can be saved if they get immediate and aggressive intensive health care. Why only one million additional patients if hospitals cancel all elective procedures and go to 12 hours on/12 hours off staffing schedules?
I have seen figures that up to 40% of the nurses in the country will either be sick themselves or will be home taking care of loved ones who are sick. If America’s divorce rate is approaching 50%, would the 40% call-out seem reasonable?
The one million additional patients is just my guess; but someone has to guess.
While we are on the subject of hospitals, with all the elective procedures and outpatient visits cancelled for about nine months, how are healthcare organizations going to be reimbursed so that they won’t go out of business during that period? We absolutely have to answer the really tough questions. Now would be an excellent time to get the details out to the healthcare industry.
Medical Facilities, Supplies and Equipment. Has anyone in the Federal government met with manufacturers and distributors of medical supplies, pharmaceuticals and equipment? I like round figures, so let’s for the sake of argument say that 100 million folks will become infected with the new strain of influenza.
How long will manufacturers take to ramp up production of all OTC medications, home health supplies and hospital supplies? Can manufacturers expect to acquire raw materials on the global marketplace? Are the manufacturers planning to go to 12-hour shifts? Is there any excess capacity to surge manufacturing at all in six to nine months? I asked that question to the X-ray film manufacturers as a part of wartime surge planning. The answer was “maybe in 12 months.” It would take that much lead time to institute such changes.
Are those who are planning to open Alternative Care Centers (ACC) planning on developing a medical logistics support plan to support the ACC? Do healthcare Materials Managers know anything at all about this ACC Concept of Operations? What about food, water (drinking, washing, and chillers), back-up generators (and fuel), regulated medical waste (RMW) treatment units? Do RMW transporters and off-site treatment facilities know anything about a surge in RMW. If quarantine is ordered, how will transporters get into the quarantined jurisdiction to pick up and transport the medical waste? The hospitals that treat RMW on-site will be very happy about their decision process. Are pre-established, anticipated demand contracts in place for all hospital services?
What about opening previously shuttered hospitals? One would think that every Public Health Officer in the county would be submitting plans and budget requests for re-opening currently closed hospitals, or more likely, former hospitals that are currently being used as office buildings, county or state buildings. Well, you would be wrong. We need to put plans and teams together across America to upgrade previously operational hospitals to be able to support at least an intermediate level of healthcare during a Pandemic.
What about mobile medical facilities? In the 1960s, America had about 1900 “Packaged Disaster Hospitals”, each with three operating rooms and each with 200 beds which were capable of attaching IV poles and medical equipment devices. These were not cots; these were beds where nurses and physicians would not have to be on hands and knees to provide patient care. That was 380,000 additional beds and 5,700 operating rooms. Each one of these “Packaged Disaster Hospitals” came with enough equipment, pharmaceuticals and medical supplies to operate for 30 days without re-supply.
Healthcare Staffing. With about a 40% reduction in healthcare providers, how will hospitals cope with “The Longest Year” in American healthcare? Are Public Health departments conducting training for healthcare augmentees? What about the Red Cross? Are their contracts for “per diem” nurses amended to accommodate the surge in demand for care givers? Are communities and hospitals involved with their state or local Medical Reserve Corps (MRC) chapter? Is the MRC expanded to include home health providers? Are provisions to care for persons with disabilities in place at Public Health departments, healthcare organizations, and the state or local MRC? Are folks going to deliver back-up power units, food, water and assistants for Special Needs and At-Risk persons on life support equipment in their homes? Are all Non-Government Organizations being fully integrated into the Public Health Department plan for community surge?
Let’s not forget that in 1918 America had a very large contingent of faith-based care givers. How capable are America’s faith-based organizations to provide various levels of patient care and end-of-life care today?
And now for the $64,000 dollar question: Will Public Health Departments across America open emergency healthcare centers and provide “hands-on” patient care? The answer is…They had better! If the Public Health Officers across America are not planning to augment the healthcare industry, which everyone knows is at or near capacity (and in many jurisdictions is over capacity), that the next “After-Event” Congressional Commission will be asking the question “Why Not?” Is it a “It’s not my job” type of thing?
What I believe wholeheartedly is that the time for plans, studies, research projects and countless articles on Pandemic is over. This anticipated Pandemic is undoubtedly the most studied Public Health emergency in world history. Never before has a disease been so studied and researched, while the society in which it was studied remains so utterly unprepared.I have developed a “Battle Plan” type of chart and enclosed it in this paper. This is just one person’s best effort at trying to hold the line during a Pandemic. Every Public Health Officer in America will have his/her own plan. At least I hope they will, for the sake of the citizens within their states and territories.
James M. Rush, CHPM, is the Vice President and Chief Operating Officer of JVR Health Readiness Inc. (formerly MEDLOG Inc.).
JVR Health Readiness is a woman-owned/ Veteran-owned Healthcare consulting and services organization dedicated to Health and Medical Readiness.
Rush has over twenty-six years of Healthcare Materials
Management and leadership experience with healthcare and
public health organizations in both the Public and Private
Sectors. He was Middle East Regional Materials Manager with
the U.S. Air Force and later served as the Medical War
Reserves (stockpile) Manager on the Surgeon General,
Europe’s staff in Germany. He later served the Army as a
civilian employee and the Chief of Medical Material
Requirements for the Readiness division of the U.S Army
Medical Material Center, Europe (USAMMCE).
You can reach Jim via email at Medloginc@aol.com
Previously on Jim Rush:
Training Citizens for Disasters [Jul 31 07]
Become a Mission Integrator [Jun 30 07]
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