In large-scale disasters that include but are not limited to detonation of an improvised nuclear device, a major earthquake, or another large hurricane striking a major US city, we will simultaneously lose health care system capacity with damage to facilities while needing to care for a surge of injured and ill people seeking care. This cannot be accomplished by a single or few facilities, but requires a region-wide plan

Chandler, Thomas E.

Kirsch, Thomas D.

Redlener, Irwin E.

Schlegelmilch, Jeffrey

Strauss-Riggs, Kandra

Disaster Medicine and Public Health Preparedness

Thomas D. Kirsch

Jeff Schlegelmilch

Kandra Strauss-Riggs

Thomas Chandler

Irwin Redlener

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Regions Respond to Catastrophes

Columbia University Academic Commons

ON THE COVERRegions Respond to CatastrophesThomas D. Kirsch, MD, MPH; Jeff Schlegelmilch, MPH, MBA; Kandra Strauss-Riggs, MPH;Thomas Chandler, PhD; Irwin Redlener, MDAs Hurricane Sandy struck the New Yorkregion on October 31, 2012, the healthsystem faced unprecedented challenges,ranging from closed and evacuated hospitals to theloss of power and depleted fuel supplies for millions ofresidents. Although the storm caused more than$71 billion in damages, with thousands of vulnerablepatients surging into hospitals and special needsshelters, few lives were lost directly from the storm.However, public health agencies, health care partners,and community-based organizations were forced bothto respond to the event and adapt to the loss of healthcare facilities with existing and ad hoc responsesystems.1In the biomedical literature, the concept of healthcare “surge capacity” became prominent in 2002, afterthe 9-11 terrorist attacks, and received increasedemphasis after Hurricane Katrina destroyed the NewOrleans health care system. The Agency for Health-care Research and Quality defines surge capacity as “ahealth care system’s ability to expand quickly beyondnormal services to meet an increased demand formedical care in the event of bioterrorism or otherlarge-scale public health emergencies.”2 Yet, as notedby Jenkins et al,3 a longstanding challenge in the fieldis that mass casualty planning is not currentlydesigned to withstand the resulting patient surgeduring such incidents, and that trauma “surges” leadto excess deaths.In large-scale disasters that include but are not limitedto detonation of an improvised nuclear device, amajor earthquake, or another large hurricane strikinga major US city, we will simultaneously lose healthcare system capacity with damage to facilities whileneeding to care for a surge of injured and ill peopleseeking care. This cannot be accomplished by a singleor few facilities, but requires a region-wide plan.PRIOR AND CURRENT NATIONAL ACTIVITIESIn the United States, several initiatives have beenaimed at improving our ability to respond to a largesurge event. There has been some, albeit limited,intra-sector and inter-sector surge planning acrossthe civilian, military, and private partners. The mostconsistent strategic impetus toward greater planninghas been through the Hospital Preparedness Program(HPP) grant program (currently administered throughthe Department of Health and Human Services’Assistant Secretary for Preparedness and Response).This funding is provided through state and localgovernments to support regional health care readiness.Between 2002 and 2015, the HPP has awarded over$5 billion to states, selected cities, and the US terri-tories to form health care coalitions with hospitals andother providers. A portion of the funds are distributedto health care providers to improve their emergencypreparedness and to encourage collaboration andmutual planning. The program’s budget has beenreduced by more than 50% over 13 years, with morecuts requested in the proposed White House budget.4Additionally, since HPP funds flow through statesand local jurisdictions, federal facilities such as USDepartment of Veterans Affairs and Department ofDefense hospitals are often not included in the coa-litions actually receiving funds.5,6After the widespread impact of Hurricane Sandy onhealth care facilities such as long-term care facilities,dialysis centers, outpatient surgical centers, and oth-ers, the Centers for Medicare and Medicaid Services(CMS) published their final rule for health careemergency preparedness in 2016. This regulationprovides a national baseline of preparedness for mosthealth care providers. This rule requires relevantfacilities to have (1) an emergency plan, (2) policiesand procedures, (3) a communications plan, and (3) atraining and testing program.7 While this creates animportant floor for preparedness among all institutionsreceiving reimbursement for services from CMS, itmerely codifies standards already put in place by theHPP and the Joint Commission and other prepared-ness standards that most hospitals already follow.8The National Disaster Medical System (NDMS)was also established and serves as a federally coordi-nated partnership of the Departments of Healthand Human Services, Homeland Security, Defense,and Veterans Affairs. Its purpose is to “support State,local, Tribal and Territorial authorities followingdisasters and emergencies by supplementing healthand medical systems and response capabilities. NDMSwould also support the military and Veterans HealthAdministration health care systems in caring forcombat casualties, should requirements exceed theircapacity.”9Disaster Medicine and Public Health Preparedness 399Copyright © 2017 Society for Disaster Medicine and Public Health, Inc. DOI: 10.1017/dmp.2017.103https://www.cambridge.org/core/terms. https://doi.org/10.1017/dmp.2017.103Downloaded from https://www.cambridge.org/core. Columbia University - Law Library, on 14 Aug 2017 at 13:32:31, subject to the Cambridge Core terms of use, available atAdditional funding through funding streams from the USDepartment of Homeland Security such as the Urban AreasSecurity Initiative and the state Homeland Security GrantProgram, as well as funding from the US Centers forDisease Control and Prevention (CDC) for bioterrorism andinfectious disease preparedness provide some resources toaugment core planning efforts, but these funds have also beenreduced and are spread across many mission areas.5,6The federal government also has the capacity to supplementstate and local health response in the event that aid isrequested and a federal Stafford Act disaster is declared.These Emergency Support Function 8 assets are looselymodeled on Department of Defense medical capabilities andinclude Federal Medical Stations, Disaster Medical AssistanceTeams, Disaster Mortuary Assistance Teams, VeterinaryMedical Assistance Teams, National Medical ResponseTeams, deployable US Public Health Service teams, theLaboratory Response Network, the CDC Strategic NationalStockpile, and Federal Emergency Management Agencyreimbursement for acute care hospital care provided during adisaster.While these assets are available within days of an event, theyare not immediately available, remain limited in scope, andare intended to provide temporary support to communities.They are not designed to assist with region-wide evacuationsor transfers that would impact health care facilities in a largeregional event.The Medical Reserve Corps (MRC), with 200,000 volunteersthroughout the country, is an important capability in manylocalities. While their volunteers are impressively engaged incommunity preparedness activities, the MRC would benefitfrom additional funding to support higher level training andincreased regional coordination.DISCUSSIONThe American health care system is not ready for a largedisaster event with hundreds let alone thousands or even tensof thousands of casualties. Such a catastrophic event, whethera natural disaster or terrorist event, will undoubtedly causedamage to some hospitals and other health care facilities,while simultaneously increasing the number of injuredseeking care. The combined loss of capacity and increasedneed could be devastating without proper planning. We mustcreate regional health care systems that allow for partial“controlled failure” of some of the facilities but are still able tosurge to provide optimum care for the injured and sick.Deploying assets from the rest of the nation cannot meet the“golden hour” needs of the critically sick and injured.Despite prior efforts, many constraints still limit the healthcare system’s ability to provide care in catastrophic disasterevents. The greatest difficulty is that most essentialcomponents of the American health care system operatewithin the private sector, even though these functionsare vital elements of the critical infrastructure necessary fordisaster response. Other aspects of critical infrastructure areeither publicly owned or heavily regulated to require pre-paredness and mitigation. Hospitals have been required tohave disaster planning for many years, and the aforemen-tioned CMS Emergency Preparedness Rule now requires17 other types of health care providers from nursing homes todialysis centers to plan and train for disasters. However,hospitals and long-term care facilities survive on a thin profit.The American Hospital Association reported that in 2014,30% of all hospitals had a negative operating margin and thatthe average operating margin was just 6.4%.10 The cost ofpreparedness and stockpiling adds further stress to these thinmargins. Private facilities also compete with one another inthe same regional market, which would require coordinatedplanning and response efforts. They have economic incentiveto compete, not to cooperate.Budget cuts for health and public health preparedness alsohave a great impact beyond the disaster-specific grantsdescribed above. The American Hospital Association statesthat if the Affordable Care Act is repealed, “Losses of thismagnitude cannot be sustained and will adversely impactpatients’ access to care, decimate hospitals’ and healthsystems’ ability to provide services….”11 In addition to thisreduction, the current budget proposes even greater reduc-tions in federal spending for health care preparedness.4In conclusion, a more comprehensive approach to health carepreparedness is required. The piecemeal approach and short-term budgeting will not create the kind of cross-sector, healthcare response infrastructure that is required to meet 21stcentury challenges. A true strategy for improving regionalhealth care surge response requires, among other things:∙ Funding and leadership to establish a stronger evidencebase for health care surge events, including modeling topredict impacts on and needs for post-disaster healthservices.∙ Operational research to identify best practices in commu-nication, coordination, and service delivery.∙ Increased and stabilized funding for the health carepreparedness programs with stronger emphasis on integra-tion with Department of Defense and Veterans Affairs(including but not limited to NDMS).∙ Stronger incentives for private sector investment inpreparedness and regional coordination.Continuing discussions among the disaster response commu-nity following Superstorm Sandy emphasized the need formore extensive and effective regional surge capacity planningas an essential component of preparing for future natural andhuman-caused mass casualty incidents likely to be moresevere and unpredictable.Regions Respond to CatastrophesDisaster Medicine and Public Health Preparedness400 VOL. 11/NO. 4https://www.cambridge.org/core/terms. https://doi.org/10.1017/dmp.2017.103Downloaded from https://www.cambridge.org/core. Columbia University - Law Library, on 14 Aug 2017 at 13:32:31, subject to the Cambridge Core terms of use, available atAbout the AuthorsNational Center for Disaster Medicine and Public Health, Uniformed ServicesUniversity, Bethesda, Maryland (Dr Kirsch and Ms Strauss-Riggs); National Centerfor Disaster Preparedness (NCDP) at Columbia University’s Earth Institute, NewYork, New York (Mr Schlegelmilch); NCDP and Teachers College, ColumbiaUniversity, New York, New York (Dr Chandler); NCDP and Department of HealthPolicy and Management, Mailman School of Public Health, Columbia University, andChildren’s Health Fund, New York, New York (Dr Redlener).REFERENCES1. Chandler T, Abramson DM, Panigrahi B, et al. Crisis decision-making during Hurricane Sandy: an analysis of established and emergentdisaster response behaviors in the New York metro area. Disaster Med PublicHealth Prep. 2016;10(3):436-442. https://doi.org/10.1017/dmp.2016.68.2. Agency for Health care Research and Quality. Bioterrorism and HealthSystem Preparedness: Issue Briefs. AHRQ website. https://archive.ahrq.gov/news/ulp/btbriefs/. Published 2006. Accessed July 20, 2017.3. Jenkins PC, Richardson CR, Norton EC, et al. Trauma surge index:advancing the measurement of trauma surges and their influence onmortality. J Am Coll Surg. 2015;221(3):729-738.e1. https://doi.org/10.1016/j.jamcollsurg.2015.05.016.4. White House. Budget for the U.S. Government. A New Foundation forAmerica Greatness. https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/budget/fy2018/budget.pdf. Accessed July 30, 2017.5. Schlegelmilch J, Petkova E, Redlener I. Disaster prepared: how federalfunding in the USA supports health system and public health readiness.J Bus Continuity Emerg Plann. 2015;9(2):112-118.6. Watson C, Watson M, Kirk Sell T. Federal funding for health security inFY2018 [published online June 27, 2017]. Health Secur. doi: 10.1089/hs.2017.0047.7. Centers for Medicare & Medicaid Services. Emergency Preparedness Rule.CMS.gov website. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html. Lastupdated June 20, 2017. Accessed July 20, 2017.8. YNHHS-CEPDR. CMS Emergency Preparedness Final Rule Crosswalk -Updated. New Haven, CT: Yale New Haven Health System Center forEmergency Preparedness and Disaster Response; 2017.9. US Department of Health and Human Services, Office of the AssistantSecretary for Preparedness and Response. National Disaster Medical System.Public Health Emergency website. https://www.phe.gov/Preparedness/responders/ndms/Pages/default.aspx. Last updated April 21, 2017. AccessedJuly 20, 2017.10. American Hospital Association. Trendwatch Chartbook 2016 - TrendsAffecting Hospitals and Health Systems. AHA website. http://www.aha.org/research/reports/tw/chartbook/index.shtml. Published 2016. AccessedJuly 20, 2017.11. Federation of American Hospitals and American Hospital Association.Estimating the impact of repealing the Affordable Care Act on hospitals.http://www.aha.org/content/16/impact-repeal-aca-report.pdf. Published2016. Accessed July 17, 2016.Cover Image:Components of a disasterRegions Respond to CatastrophesDisaster Medicine and Public Health Preparedness 401https://www.cambridge.org/core/terms. https://doi.org/10.1017/dmp.2017.103Downloaded from https://www.cambridge.org/core. Columbia University - Law Library, on 14 Aug 2017 at 13:32:31, subject to the Cambridge Core terms of use, available at

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