Mass Casualty Incidents and the Overlap Between Trauma Systems and Hospital Disaster Preparedness

The horrific mass shooting in Las Vegas on October 1, 2017 has resulted in nearly 60 deaths and more than 500 injuries at the time of this writing. The injured have been transported to a number of hospitals around Las Vegas and have overwhelmed some of the hospitals closest to the scene. A number of the injured are in critical condition and hence the death toll is likely to rise. Among other issues, this tragedy illustrates the overlap between trauma systems and hospital disaster preparedness.

A single patient with a gunshot wound (GSW) to a vital body part (e.g., head, chest, abdomen, or major artery) will stress a typical community hospital. Most community hospitals do not routinely treat these kinds of patients because trauma systems have been organized across the country over the last 50-60 years. Trauma systems consist of hospitals that have been certified as having varying levels of expertise and resources for treating trauma victims. Level I trauma centers are held to the highest standard, Level III to the lowest. University Medical Center is the only Level I trauma center in Nevada, and reports indicate that at least 30 critical patients were treated in its trauma center and more than 100 non-critical patients in the emergency department. Sunrise Hospital, a Level II trauma center and the closest trauma center to the shooting, reports having treated 180 patients and operated on approximately 30.

Today, Emergency Medical Services (EMS) ambulances will usually transport severely injured patients to accredited trauma centers, which are typically part of large academic medical centers. As a result, community hospitals rarely treat gunshot wounds anymore except for the occasional “walk-in” minor gunshot victim. Before the creation of trauma centers in the 1960s and 70s the situation was different: patients with severe traumatic injuries, including GSWs, would be taken to the closest hospital where general surgeons with varying degrees of trauma training and experience would treat them. The patient outcomes were often less than optimal.

Level 1 trauma centers have round-the-clock in-house coverage by specially trained trauma surgeons, surgical subspecialists (e.g., thoracic, cardiovascular, neuro), and anesthesiologists. In addition, they have specialized equipment—such as cardiac bypass—not often found in community hospitals. With the advent of the specialized trauma centers, patient outcomes have greatly improved but this progress has come at a price: community hospitals’ trauma capabilities have atrophied because they no longer routinely see severe trauma patients. A severe trauma patient who does somehow present to a community hospital emergency department these days is typically stabilized and transferred to a trauma center as quickly as possible. On a routine day-to-day basis, this benefits the patients, but in a large-scale trauma disaster like a mass shooting this centralization of trauma care limits a community’s surge capacity for trauma in a disaster.

While all hospitals must have disaster plans and practice them twice a year, no hospital can handle a large-scale disaster on its own—especially a complex mass casualty event. Because of this challenge, hospital disaster preparedness and response is increasingly organized around collaboration among different hospitals and between hospital and EMS, emergency management, and public health agencies. This has given rise to healthcare coalitions across the country.

Complex mass casually events of all types (e.g., chemical, biological, radiological) require highly specialized care that is only found in large academic medical centers—the same hospitals that are the Level 1 trauma centers. For the most part, community hospitals do not have the resources, depth of staff, or expertise needed for these types of events. But even the largest trauma centers can be overwhelmed by a very large-scale mass disaster. It is therefore important that trauma centers be integrated with the other hospitals in the community in a well-coordinated system that delivers the right care to the right patient in the right place—the more severe injuries to the trauma centers and the less severe to other facilities. For this to work well, it must be planned and practiced. In my view, this is best done through the emerging healthcare coalitions. As the disaster preparedness and response system continues to develop in the United States, it should be integrated with the existing trauma system with large academic medical centers being at the hub of both systems.  

Unnecessary Blindness: Hospitals Preparing for Pandemics

When the inevitable next pandemic influenza virus emerges, hospitals will be challenged to meet the requirements of a large cohort of individuals with varying degrees of illness. These patients will likely strain all the resources of hospitals including personnel, medical supplies, pharmaceutical supplies, and medical equipment. Because of the uncertainty regarding the magnitude and the nuances inherent in such events, it is a difficult task for a hospital to right-size its planning. Several tools exist, however, that have been developed to help provide estimates of supply needs including one developed by my colleagues: Panalysis.

To provide a real-world test of Panalysis, a team of us from the Center, Interdisciplinary Solutions, the University of Pennsylvania’s Wharton School, and the Mayo Clinic performed a stress test of the Mayo Clinic’s emergency pandemic supplies using various modeled scenarios. The result of that exercise was just published in the American Journal of Infection Control.

In this paper, my colleagues and I developed several different pandemic influenza scenarios of varying severity and, using Monte Carlo simulation, juxtaposed it against the specific features of Mayo Clinic and its patient catchment region in multiple iterations. Through the simulations, we could generate demand curves for certain supplies such as oseltamivir, gloves, and ventilators allowing insight into what types of demand would be expected for each of these items during various pandemic scenarios.

Using these demand curves, a facility like the Mayo Clinic could determine what level of preparedness they determined it prudent to invest in and compare current stockpiles to desired levels. For example, ventilator inventories could be maintained to be sufficient to meet the demands expected for 75% of the pandemic scenarios generated and an attendant cost generated. Similar cost-benefit analysis could be applied to N-95 respirators, courses of oseltamivir, or any other relevant item.

Every hospital will face unique challenges based on their location, services offered, catchment demographics, and size. Each will also have a differing risk calculus for preparedness and, instead of approaching this vital issue in an off-the-cuff/back-of-the-envelope manner tools such as Panalysis could be implemented to help bring rigor and quantification to these decisions allowing them to be evaluated in a manner much more fitting to their importance.

Anthrax Crisis Standards of Care

On December 4, the Centers for Disease Control and Prevention (CDC) published Clinical Framework and Medical Countermeasure Use During an Anthrax Mass-Casualty Incident.  The framework provides updated recommendations for anthrax diagnosis and treatment, specifically addressing crisis standards of care.  During a mass-casualty incident involving the dissemination of B. anthracis, demand will quickly exceed available healthcare resources, and the shift to crisis standards of care represents a fundamental change in the way medical care is delivered.  In emergency situations with relatively limited resources, healthcare professionals will need to prioritize allocation of limited time, personnel, medications, medical supplies and equipment to those who stand to benefit most.

The new recommendations build upon the 2014 CDC guidelines for prevention and treatment of anthrax to address situations where increased demand for medical care will exceed available healthcare resources.  The crisis standards of care guidelines, compiled at a March 2014 meeting of 102 subject matter experts, represent evidence-based best practices to efficiently address anthrax mass-casualty scenarios.  The clinical framework addresses four specific decision points in the clinical care of anthrax cases that would likely be impacted by limited resources.

  • Due to the high incidence of meningitis in anthrax patients, the first decision point discusses “diagnostic evaluation of anthrax meningitis” in order to determine the appropriate approach to antimicrobial therapy.
  • The second decision point helps determine appropriate antimicrobial treatment options based on their availability.
  • Considering the significant pathologic effect of B. anthracis exotoxins, the third decision point addresses use of antitoxins as adjuncts to antimicrobial therapy.
  • The fourth decision point covers identifying and draining accumulated pleural, pericardial and peritoneal fluid, which is associated with improved outcomes.

The challenges associated with each decision point and the evidence supporting the associated crisis standards of care are discussed in depth.  In addition to the crisis standards of care, the report provides conventional and contingency standards of care for comparison.  The guidance also addresses the challenges posed by pregnant and lactating women and pediatric cases, determining that both of these types of cases should be considered as high a priority as non-pregnant adults while noting that they will likely require additional monitoring and specialized care.  Finally, the report identifies areas for future research, specifically assessment of potential clinical markers to better assess disease progression in anthrax cases to support clinical care decision-making.

These guidelines provide data-driven recommendations for the dire situation where demand for life-saving therapies exceeds supply.  In the absence of a situation requiring a move to contingency or crisis standards of care, all safe and effective therapies should be used in every patient who could potentially benefit from them, even if the prognosis is relatively poor.  In a situation in which limited supplies of certain medications such as toxin-directed antibodies are insufficient, however, these scarce resources should ideally be reserved for patients who will unequivocally benefit from them.  The guidelines delineate in which situations certain therapeutic actions are appropriate and provide the treating clinician with a framework with which to provide optimal care. 

The new CDC guidance is designed to be used in preparing response protocols for or in responding to the "exhaustion (or impending exhaustion) of the capability to provide conventional standards of care," but it "does not address primary triage decisions, anthrax post-exposure prophylaxis (PEP), hospital bed or workforce surge capacity, or the logistics of dispensing MCMs."  These recommendations highlight that resource deficiencies may not affect all aspects of clinical response simultaneously, so crisis standards of care may be applied to individual aspects of diagnosis and treatment as necessary.  The guidance also caveats that clinical protocols should shift back to conventional standards of care as soon as possible.  

In the event of a mass-casualty anthrax incident, the updated CDC guidance provides clinicians with a standardized methodology for optimizing limited resources to achieve the overall greatest impact on the affected population under sub-optimal conditions. 

10 Years Later: Reflections on the Medical Response to Hurricane Katrina

In the immediate aftermath of Hurricane Katrina, my colleagues and I sought to analyze the medical and public health response to the hurricane and resulting disaster in New Orleans. Our aim was to identify lessons and suggest improvements to federal, state, and local government and private sector healthcare preparedness efforts for the next disaster. Our paper, published in 2006, found that there were critical missing elements to this response which resulted in Systemic Collapse of medical and public health systems in New Orleans at the time.

Our analysis was informed by interviews with individuals who had on the ground experience with the medical and public health response to Katrina as well as a review of news reports, government documents, and other publications that touched on the medical and public health response. Our report identified 4 key findings and provided recommendations for improvement, which we’ve presented here (“Then”), in parallel with our analysis of the current state of play (“Now”).

Finding 1, Then: Federal, state, and local disaster plans did not include strategies or provisions to keep hospitals functioning during a large scale emergency.

  • Hospitals either lacked sources of backup power, or had generators housed in basements, making them vulnerable to flooding.
  • There were no backup communications equipment or communications plans in place.
  • There was no regional or city-wide planning and coordination for the healthcare system response to a disaster.

Finding 1, Now: Since Katrina, the HHS Hospital Preparedness Program (HPP) has resulted in notable improvements to our healthcare preparedness. In particular, the formation of regional healthcare coalitions throughout the country has advanced regional planning, coordination, stockpiling, and communications capabilities. While coordination and communication can always be improved, it is clear that hospitals, public health agencies, other healthcare providers, and emergency management are more closely aligned and better at response than ever before. Most hospitals in Louisiana and other states now also have much better contingencies for essential hospital systems, although challenges remain, as seen during Superstorm Sandy, when flooded fuel pumps caused a loss of power at one hospital.

Finding 2, Then: The National Disaster Medical System was a valuable source of medical professionals. But as a whole, it did not function as a system and was ill-prepared to provide medical care to the thousands of patients who needed it.

  • Poor logistics management resulted in reduced ability for Disaster Medical Assistance Teams (DMATs) to deploy in a timely way, and teams were often separated from their supplies.
  • There were too many patients and too few NDMS personnel, who were the majority of medical responders. This resulted in NDMS only being able to provide basic triage and first aid.

Finding 2, Now: Since 2005, NDMS has deployed to other large and small disasters including tornados and the earthquake in Haiti. In general, it is still unclear how NDMS and its teams should and will be used for response. Should NDMS be highly specialized to provide advanced care, or should it be a first responder responsible for triage and basic treatment? Will it continue to be involved in international response, or is it solely a US asset? These and other questions still remain 10 years later.

Finding 3, Then: There was no coordinated system to recruit, deploy, and manage volunteers during the medical response to Hurricane Katrina.

  • There was no federal office to coordinate this response.
  • There was no way to register and verify credentials of medical volunteers in place.
  • The Medical Reserve Corps was ready to provide assistance, but was not used to its full potential often due to legal and liability concerns.

Finding 3, Now: Hurricane Katrina prompted a number of improvements in this area. We now have a system in place to register and verify credentials of medical volunteers called the Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP). Each state now has some version of this in place, although funding has been dramatically reduced in recent years. Progress has also been made in addressing legal and liability concerns; many states have reviewed and improved laws addressing VHP liability in disasters. Finally, the MRC has grown dramatically and matured in their approach to both everyday health threats and disasters.

Finding 4, Then: Hurricane Katrina separated many Gulf Coast residents from their medical records, leaving VHPs without medical histories to help guide patient care.

Finding 4, Now: We’ve come a long way since 2005 in the area of electronic medical records and personal health records. In 2009, only 11.9% of hospitals and 22.8% of office-based physicians had any kind of electronic medical record system. Now, over 95% of hospitals and 54% of office-based physicians in the US not only have electronic medical records, but have demonstrated meaningful use of those systems according to CMS requirements under the American Recovery and Reinvestment Act of 2009. Similarly, pharmacies across the US have also adopted electronic, redundant records systems. Challenges remain in interoperability between records systems, with public health agencies, and with laboratories, but great strides continue to be made in these areas.

Ten years later, the US has faced a number of other tests of our health system’s preparedness including tornado outbreaks in the Midwest, infectious disease emergencies like the H1N1 influenza pandemic and Ebola, and other extreme weather events, including Superstorm Sandy. While every disaster serves as a learning experience, and much work remains to be done, in the intervening years since Hurricane Katrina, we have witnessed demonstrable improvements in our ability to handle large disasters and maintain responsive, high functioning healthcare and public health systems, and we hope that trend continues.   

Too Many Patients, Too Few Resources

From: Chipotle

How do you decide who gets access to life saving medical resources like a ventilator when there are not enough to go around in a catastrophic disaster? My colleagues and I, along with collaborators at the Johns Hopkins Office of Emergency Management, School of Medicine and Berman Institute of Bioethics and Resolve, have been wrestling with this question for the last several years. Other researchers and experts have convened working groups and task forces to draft expert guidelines. We think their efforts have been very valuable, but we decided to approach the problem from a different angle. We decided to ask the public first.

For the last 5 years, we have been developing and running a community engagement research project asking lay people and healthcare workers in Maryland what ethical principles they think should best be used in allocating scarce resources. Specifically, we have conducted 15 day-long community engagement forums across the state over the last 2 years, asking Marylanders about what values they think should be applied when deciding who should get priority for a ventilator in a severe pandemic when there may be many times more patients with respiratory failure then there are ventilators to go around. I presented some findings from this work at the 3rd annual National Healthcare Coalition Preparedness Conference in Denver recently, and we will be presenting even more findings at the 2015 Preparedness Summit in Atlanta in April. The findings of this work will inform recommendations to be made to the State of Maryland for inclusion in a potential future Crisis Standards of Care plan.

For this project we used a “deliberative democracy” approach designed by the Carnegie Mellon University Program for Deliberative Democracy. In this approach, community members engage in small group discussions with trained facilitators. The goal is not to create consensus but rather to capture the many different ways that people think about such difficult decisions. The magic in this process is to see how people’s strongly held opinions evolve over the course of a thoughtful discussion.

We found that, universally, the participants were able to understand the ethical principles involved and work in constructive and civil discourse with others who hold different views. They were able to think creatively about the issues and apply their own personal values in thoughtful and nuanced ways. This was true whether the forum was held in a blighted inner city neighborhood, a wealthy suburb or a rural community. We did, however, also find that the community in which someone lives does play a role in how one think as about such things, especially when it comes to aspects such as social justice and access to care.

I used to think that a measure of success was getting on the cover of Rolling Stone (in the ‘70s) or Time (in the ‘90s) but now it appears that the measure of success is being on the cover of a Chipotle bag! Chipotle asked prominent authors to write short essays that they have printed on their bags, and Sheri Fink is one of the authors. Sheri, who won a Pulitzer Prize for her reporting on Hurricane Katrina, has been following our project from its inception and decided to make her essay on the bag about this project. She also wrote about the project in the epilogue of her bestselling book Five Days in Memorial.

What’s really important about this work, I think, is not which ethical principle (or combination of principles) is found to be most popular but that it shows that community members can constructively participate in such deliberations. It is important that a plan to allocate scarce resources reflects the values of the community as much as possible. But, as we have found, there is not one set of values, but many. To be able to reflect these values, we first need to understand them. We also found that you cannot get at these values through a simple poll or survey. As our project has shown, people’s opinions change as they engage in deep discussion—this is when their true values come out.

The Growth and Future of Healthcare Emergency Preparedness Coalitions

From: MSCC Handbook, PHE.gov

From: MSCC Handbook, PHE.gov

Last week I attended the 3rd annual National Healthcare Coalition Preparedness Conference in Denver. This has grown to be one of the premier healthcare preparedness meetings with well over 700 attendees from all over the country. There were a number of interesting presentations on a wide variety of preparedness topics, including my own presentation on allocation of scarce resources in a disaster that I will address in a future post. In this post I will focus on the tremendous growth that has been seen in preparedness coalitions and their possible future.

Phenomenal growth

In a really informative presentation by Melissa Harvey Deputy Director of the Hospital Preparedness Program (HPP) in the Office of the Assistant Secretary for Preparedness and Response (ASPR) in the Department of Health and Human Services (HHS), I learned that there are now approximately 500 coalitions. These coalitions have almost 24,000 members, which represents a 47% increase since last year. Most of the coalitions include the “big 4” as members: hospitals, public health, emergency management and emergency medical services (EMS). As we and many others have said in the past, all coalitions are different and that “if you have seen one coalition you have seen one coalition”. But many speakers at the conference endorsed the notion that many different coalition structures can be effective.    

Going forward, HPP’s goal is to broaden coalition membership to the “next 3” namely: home health, dialysis centers and nursing homes. They also want to increase coalition membership by another 100% to 48,000 in the coming year. This seems like an ambitious goal but they think that the coming emergency preparedness rule from the Centers for Medicare and Medicaid (CMS), which is due out in about a year, will provide a strong incentive for healthcare facilities to join in coalitions. While the CMS draft rule does not mandate coalition membership, it does require CMS providers to collaborate with local partners and encourages coalition membership.

Future sustainability

While on the one hand this growth in coalition is very encouraging, I see potential financial problems down the road. The CMS rule is a stick without a financial carrot. Healthcare facilities will be penalized for not meeting the requirements but are not provided additional funds to do so. Currently most hospitals get this funding from the HPP; however, the HPP has seen an almost 50% decrease in budget over the last 10 years and its future after 2017 is not guaranteed. So the question of financial sustainability of coalitions looms large in the minds of many coalition leaders as expressed at the conference.

One intriguing potential solution to this dilemma, articulated by Brendan Carr from ASPR, is to expand the scope of coalitions beyond emergency preparedness and response.  Coalitions largely overlap with regional referral networks (such as trauma, cardiac and stroke referral systems). As we as a nation move gradually to a healthcare system organized around regionally determined outcome measures, existing coalitions could be a vehicle through which healthcare facilities collaborate to improve population based outcomes and constrain costs.  This should be food for thought for coalition leaders and healthcare planners alike.