Maurice A. Ramirez, DO, CNS, CMRO

What Would They Say Today?

Eighteen months after the terrorist attacks of 9/11, America’s healthcare leadership announced that while they had not been ready on September 11, 2001, now they were. On March 13, 2003, in a much ballyhooed statement, still sited to this day, the American College of Healthcare Executives announced:

“HOSPITAL CEOs SAY BIOTERRORISM PLANS ARE IN PLACE CHICAGO

Since September 11, 2001, hospitals have faced new challenges protecting and caring for their communities, especially the threat of bioterrorism. According to a new survey conducted by the American College of Healthcare Executives (ACHE), 84 percent of hospital CEOs agree that since 9/11, their hospitals have worked more closely with public agencies (e.g. fire, police, and public health departments). Further, 95 percent of the respondents said their hospitals already have, or within six months will have, a bioterrorism disaster plan in place, developed in coordination with local emergency or health agencies.”

Little did they know the sense of false security and the cooling of momentum this assertion would cause from that day forward.

The Clear View of Reality

Since 2003, multiple independent evaluations of hospital preparedness and hospital disaster planning have found the reality in each successive year to be far below that purported in 2003. A brief survey three reports by the Institutes of Medicine in June, 2006 serve as proof that any hint of hospital preparedness is false and that momentum towards preparedness has been lost. These reports, Hospital-Based Emergency Care: At the Breaking Point, Emergency Care for Children: Growing Pains, and Emergency Medical Services at the Crossroads found a disparity between self reported preparedness on multiple association and government surveys compared to actual preparedness measured across the five core indicators of hospital preparedness.

“Evaluations of ED disaster preparedness consistently yield the same finding: EDs are better prepared than they used to be, but still fall short of where they should be”

At first blush, this seems to confirm the ACHE assertions, but the report goes on to point out that hospitals lack patient surge capacity due to cost related downsizing, nursing shortages, loss of specialists, physical space constrains and overcrowding. Failures of planning and coordination were also identified and linked to erroneous planning assumptions.

“When a disaster occurs, the normal operating assumptions about patients, responses, and treatments often must be jettisoned. Depending on the type of event, some of the nonroutine things that can happen include the following:

• Victims who are less injured and mobile will often self-transport to the nearest hospitals, quickly overwhelming those facilities.
• Casualties are likely to bypass on-site triage, first aid, and decontamination stations.
• EMS responders will often self-dispatch. Providers from other jurisdictions may appear at the scene and transport patients, sometimes without coordination or communication with local officials.
• In some cases, local facilities are not aware of the event until or just before patients start arriving. Hospitals may receive no advance notice of the extent of the event or the numbers and types of patients they can expect.
• There may be little or no communication among regional hospitals, incident commanders, public safety, and EMS responders to coordinate the response region wide.”

The Institute of Medicine reports goes on to call for improved communications and integration across disaster response services including Emergency Medical Services (EMS), community emergency operations and most importantly the implementation of the standardized Incident Command System.

“To respond effectively, hospitals must interface with incident command at multiple levels and be prepared to deal with transitions between levels, for example, when incident command shifts from the local to the state or federal level. Each hospital should be familiar with the local office of emergency preparedness and know how hospitals are represented at the emergency operations center during an event, whether through the hospital association, the health department, the EMS system, or some other mechanism.”

They Didn’t Think of That Either

Beyond the problems common to all disaster care environments, special needs populations (children, elderly, mentally and physically challenged) have needs and preparedness issues unique to them. Unfortunately, the “one size fits none” approach taken by America’s hospitals has ignored issues highlighted by the Institutes of Medicine Emergency Care for Children: Growing Pains report.

“The needs of children have traditionally been overlooked in disaster planning. Historically, the military was considered the only target of potential biological, chemical, and radiological attacks, so the focus for training, equipment, and facilities was on the care of healthy young adults.”

“Younger patients require specialized equipment and different approaches to treatment in the event of a disaster. Children cannot be properly decontaminated in adult decontamination units because they require adjustments to the water temperature and pressure (heated, high-volume, low-pressure water). Rescuers also need to have child-size clothing on-hand for use after the decontamination.”

The problems are compounded for rural hospitals. Despite the fact that many both inside and outside hospital leadership believe that rural hospitals are at lower risk and thus require less commitment to preparedness, the truth is quite the opposite.

“The focus of emergency preparedness has been on urban areas in part because of the perceived increased risk of terrorism in these areas. However, there is a danger associated with neglecting rural areas. Indeed, one might argue that rural areas may be even more vulnerable to a terrorist attack. Many nuclear power facilities, hydroelectric dams, uranium and plutonium storage facilities, and agricultural chemical facilities, as well as all U.S. Air Force missile launch facilities, are located in rural areas and are potential targets for attack. Additionally, if individuals with infectious diseases, such as smallpox, enter the country through Canadian or Mexican borders, rural providers may be the first to identify the threat.”

A Problem of Their Own Making

The greatest indictment of hospitals by the Institute of Medicine Reports however dealt with disaster preparedness training and drills finding great variability in the training of even key healthcare personnel with even less training for non-clinical hospital staff.

“Serious clinical and operational deficiencies, fragmentation, and lack of standardization exist across a broad spectrum of key professional personnel (nurses, physicians, ancillary care providers, administrators, and public health officials) in both individual training and coordination of a team response.”

This failure to provide training not only effects patient care, but hospital employee safety. Despite public statements by hospitals that “safety is worth the cost” and “preparedness is priceless” The American College of Emergency Physicians (ACEP) and the Agency for Healthcare Quality and Research (AHQR) separately found a very different financial and leadership commitment to preparedness and training.

“Many hospitals report inadequate funding to cover the attendance costs (e.g., time off, tuition, travel) of training (ACEP, 2001). At the University of Pittsburgh Medical Center, a disaster drill in the Emergency Department costs $3,000 per hour in staff salaries alone (AHRQ, 2004).”

“Additionally, the failure of hospital administrators or Emergency Department personnel to recognize the importance of training can result in a lack of support (ACEP, 2001).”

Multiple agencies, including the Institutes of Medicine have called for an increased coordinated financial commitment to preparedness on the part of individual hospitals, hospital corporations, hospital management / holding companies, as well as local, state and federal governments.

“This lack of coordination is reflected in the haphazard funding of preparedness initiatives. EMS and trauma systems have consistently been underfunded relative to their presence and role in the field.”

“States and communities should play an important role in determining how they will prepare for emergencies. To the extent that they are supported in this effort through federal preparedness grants, the critical role and vulnerabilities of hospitals must be more widely acknowledged, and the particular needs of hospitals and hospital personnel must be taken explicitly into account”

Despite this, funding for preparedness has decreased across the board including congressional cuts in healthcare preparedness funding for 2007, 2008 and again for 2009. These cuts have been mirrored in state funding initiatives; meanwhile hospitals continue to believe that they are prepared despite evidence to the contrary.

So What Should They Say Today?

Given these realities leaders in the field of healthcare and hospital management must now confront the fact that self reporting on preparedness is a failed method, no different than asking a 10 year old to grade their own final exam. With the curtain pulled back it is time for healthcare and hospitals to say:

“It is our corporate and personal responsibility to ensure the safety and preparedness of our entire staff, clinical and non-clinical as well as prepare to respond to the needs of the patients we serve every day and the patients we will serve when disaster strikes.”

The problem is that healthcare and hospital leaders have done everything in their power to quietly avoid the need to make this statement much less bring this statement into reality. In the two years since the Institutes of Medicine published their reports, hospitals have lobbied first to delay and forestall the deadlines for both Joint Commission preparedness guidelines and National Incident Management System (NIMS) compliance elements. The effect of this has been to make such things as facility beautification a higher financial priority than facility preparedness.

What is Needed?

While the Institutes of Medicine and many other organizations have made recommendations to improve hospital disaster preparedness, the sad fact is that the only way to force hospitals to properly and adequately prepare is to enforce the existing guidelines, mandate meaningful external certification of compliance and engage the public in demanding local hospitals “just do it.” There is an old adage in healthcare law:

“No change in healthcare has ever come without regulation, legislation or litigation.”

Enforcement of existing guidelines will require that the applicable government agencies including the Department of Homeland Security, FEMA, the Department of Justice, the Department of Health and Human Services and the Center for Medicare Services mandate full and complete NIMS compliance by the original September 30, 2008 deadline. Further, these agencies must be willing to use the full force of law to induce hospitals to invest in preparedness rather than pianos and fountains. Federal preparedness legislation carries with it implications of Medicare fraud, Sarbanes-Oxley violations and federal false claims issues. It is an unfortunate reality that government must all too often prosecute to create compliance.

The private sector has a responsibility to enforce preparedness guidelines as well. Joint Commission has repeatedly chosen to “partner with hospitals” rather than “punish” the recalcitrant faculties who repeatedly delay and curtail preparedness efforts. Joint Commission accreditation is a powerful force for change in hospital healthcare. The current tendency of hospitals to do as little as possible as slowly as possible necessitates that Joint Commission enforce the original preparedness compliance deadline in January of 2009 rather than permitting yet another extension.

Perhaps the best thing everyone in healthcare oversight and leadership can say to the American people is:

“We’re Sorry and We Will Do Better!

The Unprepared Beware

Last year a High Alert, LLC white paper had raised the specter of NRP/NIMS compliance being linked to CMS (Medicare, Medicaid and Tricare) billing, the discussion had been strictly theoretical. Several federally funded training programs have now brought to the table a new and ominous implication of the NIMS Integration Center Implementation Plan for Hospitals and Healthcare. Additionally, hospitals have reported being informed that disaster preparedness will be linked to CMS reimbursement (Medicare, Medicaid and Tricare payments).

Almost immediately, a National Incident Management System (NIMS) update alert from the NIMS Implementation Center, included obscure reference to a frequently asked question (FAQ) document on the FEMA website.  This document, posted on April 20, 2007, like many documents before it was deeply buried within the FEMA website, accessible only to those who knew where to find it. 

The last two questions on this FAQ document dealt with a raging debate regarding the repercussions of failing to be NIMS compliant before the looming September 30, 2007 deadline. 

The first answered the question of whether the Joint Commission required NIMS compliance for accreditation.  The answers stated “Not at this time.”

The second question similarly was a response to inquiries regarding whether CMS required NIMS compliance for Medicare and Medicaid benefits and reimbursements.  Again the answer was “Not at this time.”

Times have changed.

On October 18, 2007, President George W. Bush signed Homeland Security Presidential Directive 21 (HSPD-21) into law establishing the new specialty of Disaster Healthcare and fulfilling many of the predictions of the original High Alert, LLC white paper. HSPD-21 is available for download here:

Download HSPD-21.pdf

High Alert, LLC published a new white paper on the implications of HDPS-21, Sarbanes-Oxley (SAR-OX) and Federal False Claims (FFC) legislation for healthcare law and disaster healthcare. The new High Alert, LLC white paper is available for download here:

Download preparedness_and_the_force_of_lawrevised_20oct07.pdf

Each of the critical infrastructure industries identified in the National Response Plan (NRP) and the National Incident Management System (NIMS) have similar HSPD’s. The correlations made regarding healthcare law can easily be extrapolated to each of these critical infrastructure industries as well.

Although the federal government has not acted on these possibilities, they are very aware of the potential. FEMA even issued a series of statements directed to hospitals indicating that FEMA has no plan to pursue SAR-OX or FFC’s action under HSPD-21. The problem is that it is the Department of Justice (DOJ), not FEMA who pursues such claims and FEMA does not speak for DOJ.

This white paper has been vetted through contacts in D.C. and while not confirmed as an active plan, no part has been refuted except in the afore mentioned FEMA statements. However, the observations in this white paper is bolstered by the recent alignment of Joint Commission guidelines with NIMS guidelines. These Joint Commission changes occurred after the publication of the white paper, but were predicted despite the insistence of FEMA that such Joint Commission changes would not occur. It is now anticipated that Emergency and Disaster Preparedness will become a Core Performance Benchmark for Joint Commission in 2009. Given that Joint Commission is now provides de facto the Medicare and Medicaid compliance inspection, these 2009 changes will complete the alignments described in the white paper.

The Unprepared Beware!

Blink or Slight of Hand - Hospitals Beware!

A recent National Incident Management System (NIMS) update alert from the NIMS Implementation Center, included obscure reference to a frequently asked question (FAQ) document on the FEMA website.  This document, posted on April 20, 2007, like many documents before it was deeply buried within the FEMA website, accessible only to those who knew where to find it. 

The last two questions on this FAQ document dealt with a raging debate regarding the repercussions of failing to be NIMS compliant before the looming September 30, 2007 deadline. 

The first answered the question of whether the Joint Commission required NIMS compliance for accreditation.  The answers stated “Not at this time.”

The second question similarly was a response to inquiries regarding whether CMS required NIMS compliance for Medicare and Medicaid benefits and reimbursements.  Again the answer was “Not at this time.”

The April 20th update was posted almost exactly three weeks to the day after High Alert, LLC.  privately circulated a pre-released draft of its white paper on the association of NIMS, NRP, the NIMS Implementation Plan for Hospitals and Healthcare, the Federal False Claims Act (Qui Tam) and the Sarbanes-Oxley Act.  In that much circulated document, High Alert referenced several early positions by the Justice Department and the NIMS Implementation Center that placed hospitals and other healthcare facilities at risk of Medicare fraud and the repercussions of that fraud under both Federal False Claims Act and Sarbanes-Oxley. 

High Alert sounded the claxton alarm warning that failure to be NIMS compliant while still billing Medicare and Medicaid could constitute a violation of the Federal False Claim Act, thus opening institutions to significant legal repercussions. 

Several legal scholars had reviewed this potential and concurred with High Alert’s conclusions, adding that willful blindness regarding NIMS Compliance does not constitute a defense.  Similarly, the fact that Federal False Claims complaints are sealed for the first 120 days would by necessity mean that healthcare facilities and hospitals filing Sarbanes-Oxley Reports while under a Federal False Claims complaint would be guilty of a second violation, that being a false Sarbanes-Oxley Attestation. 

Several officials within the Department of Homeland Security, FEMA and Department of Health and Human Services requested copies of the High Alert draft document in the weeks prior to its official release in early April.  Within a week of the release of High Alert’s white paper the FAQ statements were posted to the internet. Interestingly, it was not until late June that the existence of these clarifications was publicized.

This raises the specter of a continuing plan to place hospitals and healthcare facilities in danger of violating of both the Joint Commission Accreditation guidelines and the Federal False Claims Act for failing to be filling NIMS compliance by the September 30 deadline. 

Hospitals and healthcare facilities can take a little solace in the fact that this FAQ document state “not at this time” in response inquires that the possibilities raised by High Alert’s document will result in actual federal prosecution.

There further persists the question of whether or not a private relator can bring Qui Tam action under the Federal False Claims Act, despite the fact that the federal government is currently disallowing any intention of bringing such claims on its own, “at this time.”

The history of the Federal False Claims Act demonstrates that enforcement has been primarily at the hand of private citizens acting in the function of “relator” bringing Qui Tam actions thus ever expanding the application and implication of the Federal False Claims Act.

The legal connections between liabilities under Federal False Claims and the Sarbanes-Oxley Attestation has been well-established both by High Alert and by others.  Thus when Qui Tam actions are successfully argued for failure to comply with NIMS hospitals and their corporate executives would face serious legal jeopardy.

Of even greater concern is the fact that even if a Qui Tam action were unsuccessful, the fact that the Qui Tam action may not be disclosed by any party requires that the existence of this potential liability be omitted from any Sarbanes-Oxley report filed during the corresponding time frame. This willful omission of a potential liability is the very definition of a Sarbanes-Oxley disclosure violation. Due to this legal “catch 22,” the CEO and CFO who signed the fraudulent Sarbanes-Oxley Attestation face civil and criminal prosecution.

The recent NIMS Integration Center alert and its associated FAQ document may allay the fears of hospitals as they move forward quickly to meet the September 30 implementation deadline. However, those facilities who view this document as reassurance that there are no significant repercussions for failure to be NIMS compliant may find that the copies of the High Alert document circulated at the Department of Homeland Security, FEMA, the NIMS Implementation Center and CMS served as a template for NIMS enforcement.

The ultimate question is, did the Federal government blink or is this a bit of informational sleight of hand?

One Great Solution for Improving Healthcare Preparedness

Our nation faces two interesting challenges when it comes to the healthcare response to disasters.  The first is that according to an Institute of Medicine report published in June 2006, hospitals have by and large failed to meet even the most basic standards for disaster preparedness.  In other words, they have failed to develop the relationships within their own communities, ignoring even EMS and community-wide Emergency Response Services thus failing to integrate these critical services into the hospital disaster plan.

Further, most hospitals, now six years after 9/11, still fail to provide basic disaster response training to all of their employees. Basic Incident Command training that would allow their employees and care providers to integrate themselves into the community wide response, while required by federal guidelines, is still reserved for members of the administrative team. Most hospitals have even failed to hold or participate in community-wide Disaster Drills despite a four year old mandate for these drill each year. Although reasons cited by hospitals for their failure are many, they are also largely invalid.  Requirements have existed for such Community-Wide Disaster Drill since 2003 and since 2002, the federal government had paid for or provided free of charge the educational opportunities for hospital employees.  Unfortunately now, most of that federal funding has ended, the five-year grants have expired.

There is however one opportunity for the federal government to use existing assets, augmented by existing state government assets, to provide not only training but disaster drill opportunities to hospitals and other portions of healthcare.  The Natural Disaster Medical System (NDMS) has within its ranks Disaster Medical Assistance Teams (DMAT) who are trained in all aspects of incidents command, disaster vulnerability analysis, disaster planning, disaster response, and disaster recovery.  Individuals who make up DMAT teams are civilian healthcare professionals who, when not deployed by our federal government, function as unpaid reservers, part-time federal employees on stand-by status, receiving no pay while remaining on call and ready to deploy within two hours in the event of national disaster or terrorism.

DMAT teams represents the perfect opportunity for federal government to utilize an asset already in the federal budget to provide not only training to hospitals in the communities surrounding a DMAT team, but community wide, externally designed and graded disaster drills that would include not only the hospitals but fire rescue, law enforcement, local county and even state emergency operations integrated with state and federal disaster response assets in coordinated community-wide drills. In other words, the best possible practice model. 

Expanding the services offered by DMAT teams to their surrounding communities would also serve the objectives of the federal government by providing an opportunity for DMAT teams to hold Field Training Exercises (FTX’s) and to network with healthcare assets in the surrounding communities.  NDMS has sought for years to develop a network of participating hospitals who would accept patients from distant field disaster sites transported by military or other assets and requiring hospitalization outside of the disaster zone. 

The average hospital will spend between $90,000 - 180,000 per year in the coming decade just for disaster drills and training, and this does not include the cost of paying employees to participate in those drills and training opportunities. Participation in federally sponsored federally funded, DMAT based disaster training and exercises would represent a significant inducement to hospitals  to join the NDMS hospital system and a significant benefit to NDMS member hospitals. 

State medical response teams, known under various names in various locations, could provide a similar opportunity for the state to both build relationships between their teams and their communities as well as improve the operational efficiency of teams through exercises and education.

Conceivably, even Medical Reserve Core units (MRC) could participate by providing local leadership and coordination efforts for their hospitals and communities as the MRC provides the earliest possible disaster response, providing for healthcare needs in those initials hours after an event.

Certainly, there will be the challenges of Congressional funding and special interest groups claiming that the federal government is subsidizing programs that benefit for profit hospitals.  More importantly however, a program such as this would ensure that our healthcare infrastructure was maximally prepared for the next Hurricane Katrina, for the next Oakridge earthquake, for the next Americas Georgia tornados, for the next great river flood.  NDMS member hospitals deserve to receive some benefit for becoming an NDMS hospital and assuming the additional responsibilities that come, uncompensated, with agreeing to participate in America’s disaster healthcare response system.  Using DMAT teams to train, drill and evaluate America’s healthcare infrastructure will ensure that the survivors of disaster receive the best healthcare available while the rest of us rest assured that our community’s healthcare is truly prepared if the disaster comes to our doorstep.

Three Simple Rules for Media Relations

In the disaster field office there are three simple yet absolute rules to managing media relations. Businesses, celebrities, and even hospitals have created for themselves foibles and catastrophes due to a basic lack in the ability to manage media relations and the press.  These problems stem from the fact that most failed to understand that the press serves the same people that they serve.  Whether you are a corporation, a small business, a healthcare facility, or a movie star the press speaks at one time en masse to your public.  If you remember this simple fact it is then no great intellectual stretch to understand that by partnering with the press and the media you can communicate vital information to your entire market simultaneously.

Rule Number One: Don’t get in front of the camera!

This may be obvious but if it is not your job to speak to the press do not get in front of the camera. Moreover ensure that your employees and staff do not get in front of the camera unless it is their job to interface with the media.  Most media mishaps occur because the press is presented with multiple messages and good, honest reporters attempt to make some logical sense of these conflicting stories. 

Unfortunately no matter how good the reporter and how well meaning your staff when conflicting stories enter the press simultaneously nothing but bad can come of it for your organization.

Rule Number Two: Do not lie!

Now this is probably good advice in life in general, but if you lie to the press they will catch you and then they will make it their mission in life to destroy your career because you have just done irreparable damage to theirs, you have damaged their credibility.  The media succeeds because people trust them.  If they violate that trust no matter how unintended or innocent the violation they lose the public trust.  With this loss of credibility comes the loss of the ability to do their job.  Therefore everything that you say must be absolutely true and absolutely consistent with what the reporter observes.

Rule Number Three: Remember how the press keeps score!

The media does not keep score the same way that you do. 

• They do not count dollars.
• They do not count lives saved.
• They do not count how many movies they appear in. 

The press keeps score either in terms of minutes of face time on camera or inches of newsprint.  In order for the press to score they must capture 1.5 seconds of you, approximately 15 words in print, and surround it with several minutes of themselves, at least 2 inches of newsprint. 

If you know what message you wish to communicate to your market, their audience, and you must:

• Condense your message into a 1.5 second sound bite (fifty words for print).
• Ensure that message is absolutely true and consistent with what the reporter sees.
• Deliver that same message regardless of the question asked.

Do these three things and you will leave the reporter with only one choice, use your message or to not score today.  Under those circumstances the media will use your message every time because they keep score based on minutes of face time or inches of newsprint and to score they must surround your message with their voice or their prose. 

Remember these lessons from the disaster field office and your next media encounter will serve to bolster your relationship with the media and your position both with the press and the community. 

Disaster Medicine: Beyond the ER

In the year since 9/11 disaster medicine has come into its own.  Now a recognized specialty the practice of disaster preparedness, disaster planning, disaster response and disaster recovery as it relates to the practice of medicine and the function of healthcare and healthcare institutions has moved from the realm of the emergency manager and hospital safety officer and into the realm of the healthcare professional.  As with any burgeoning specialty, disaster medicine drew from its strengths and grew from its roots.  Disaster medicine had its beginnings in the disaster field office.  Field response units formulated much of the early information regarding the practice of this newest medical specialty. 

Just as patients flow from the field to the hospital decontamination a triage in decontamination arena the science of disaster medicine grew next in the areas of triage and hospital-based decontamination.  Soon nonemergency room staff were being drawn from their primary duties on the hospital floor to actually step outside the hospital to provide triage and initial treatment in the event of a mass casualty incident.  From the triage and decontamination tents disaster medicine moved quickly into the emergency department bringing with it new concepts in toxicology and mass casualty patient care.  Lessons drawn from military medical experience and from civilian emergency room experience melded in textbooks as well as discussion groups that inside disaster medicine and within the hallowed halls of the emergency medicine professional organizations.

But in this expanding universe of knowledge the hospital floor and the Intensive Care Unit were all but forgotten.  Michael Osterholm and others have discussed the impact of mass casualty events and pandemic influenza on the ability of hospital Intensive Care Units and other high acuity departments to meet the needs of a disaster response.  Unfortunately while models created by Schultz and Ramirez had demonstrated that with a small application of behavioral health savvy surge capacities can be increased not only by the required 20 percent under the US Department of Health and Human Services guidelines but by as much as 400 percent, this vast expansion of surge capacity rely in small part on the ability of the inpatient services to accommodate additional admissions.  A simple review of historically corrected pandemic predictions compared to hospital capability surveys demonstrates the dangers of not expanding hospital inpatient capacity as aptly as intake capacity has expanded.

When the lessons of the disaster field office are applied to businesses these businesses learn first to determine what is the goal of their organization.  In the intensive care unit and other high acuity areas of the hospital the goal is the same as it is in a field disaster hospital, the preservation of life.  In the environment of the intensive unit triage has already taken place for you.  These patients are already determined to be critical and further triage can only serve to determine which individual's care will utilize so many resources as to endanger the care of two or more other individuals.  In this circumstance it is the absolute moral and ethical obligation of those providing the care to make a resource-based decision.  When the continued care of one patient will utilize sufficient resources to endanger the care or life or two or more others then the care of that one patient, then that one patient must be reassigned to the expectant (black tag) treatment area.  This is not a do not resuscitate order (DNR).  This is simply a statement of available resources.  Patients are constantly re-triaged based on available resources and current medical conditions.  A critical patient upon the loss of vital resources may temporarily be moved to an expectant category until resources or conditions are such that the patient may be re-triaged back to a critical or possibly has improved sufficiently to be "downgraded" to triage category yellow (urgent).

On the other hand, if treatment of an ICU or a high acuity patient does not utilize sufficient resources to endanger the care of two or more other individuals then that high acuity care should and in fact must continue as an ethical and moral imperative.

The key to making these decisions is to identify the critical processes that are required for the provision of essential high acuity medical care.  Once these processes are identified specific, measurable parameters must be established to determine if additional resources are needed to bolster that process.  This ensures that valuable limited resources are not squandered on processes that are not in danger of collapse as a result of surge.  More importantly, as the number of patients under treatment expand it ensures that resources are wisely allocated to maximize the surge capacity.

Resources will always be limited in a disaster because of the very nature by which resources are now obtained.  Our "just in time economy" has eliminated most stockpiles from healthcare institutions.  Few hospitals have more than two or three days worth of medication, disposable supplies or food on hand at any given moment.  They rely on regular re-supply from vendors, who themselves maintain only limited warehouse storage.  In the event of a large scale disaster needs quickly exceed resources (the very definition of a disaster) and supply chains break down.  With resources even further limited essential processes fail and a disaster becomes a catastrophe as the ability to respond is lost.

The frugal application of resources to essential processes in the provision of healthcare combined with a continuous re-triage of patients ensures that precious resources are utilized in a fashion which maximizes their impact and benefit.

This lesson has already been implemented in virtually every hospital in the United States, but it has not been implemented in a patient care area.  Information technology departments utilize the constant monitoring of key operational processes with clear and well-defined parameters to determine how best to dynamically shift available resources.  Your information technology professionals speak in terms of "bandwidth" rather than "bed space" and "memory allocation" rather than "ventilator availability."  However, with well over a quarter century experience in process analysis and resource allocation, your information technology professional is an invaluable resource in the method of evaluating your essential processes and resource allocation.

Virtually every supplier of data management equipment and software, from imaging to electronic medical records to registration and accounting software are utilizing this process to ensure continuity of their part of the operation.  Patient care component is the only portion of hospital operation that has not learned to triage itself.

A careful evaluation of the healthcare process utilizing these information technology techniques will quickly show that in addition to those items already on our resource list including medication, food, bandages and other disposable supplies the most valuable and most limited resource is the healthcare professional themselves.  It has been said that it takes at least seven years to grow a doctor, at least two years to grow a nurse or a respiratory therapist and many more years to ensure the experience necessary to operate in these professions and every other patient care profession with any degree of expertise.

The loss of a healthcare professional through injury, illness, or stress has a significant negative impact upon both operational capacity during a disaster as well as the short and long-term recovery following the disaster.  Lose just one of these professionals and you impact the care of thousands or even tens of thousands of patients into the future.

Ensuring the resilience of healthcare professionals within the high acuity arenas of the hospital is the single most effective and most efficient means of expanding surge capacity beyond the emergency department.

There are six areas of human functioning:

• Physical
• Emotional
• Intellectual
• Social
• Behavioral
• Spiritual

Each of these areas of human functioning have a corresponding form of resilience, a canteen which is filled in the time between disasters and drawn from during the response to a disaster.  These six canteens of resilience are:

• Physical
• Emotional
• Intellectual
• Relationship (social)
• Functional (behavioral)
• Spiritual

Physical resilience is exactly as the name would imply.  It is the physical capacity to continue working in light of physical and even emotional stress.  Physical resilience is enhanced through the maintenance of good health and a healthy lifestyle.  Eating a balanced diet both at home and at work, including during the disaster; regular exercise; and adequate rest, even during the disaster, are essential to "filling" your canteen of physical resilience and maintaining that resilience while responding to a disaster.

Emotional resilience deals directly with what we feel and how we respond to it.  The old saying "attitude counts" was never more true than when filling your canteen of emotional resilience.  Loving and being loved, including loving yourself; enjoying the everyday joys of life and ensuring that you have the opportunity for boundless joy and genuine happiness fill your canteen with the sweet emotions that counterbalance the many unpleasant and at times even horrific scenes that we all encounter when responding to disaster.  On the other hand, if you have filled your emotional canteen with despair; selfloathing; angst and animus then you will have nothing but bitter drags from which to drink when in the midst of a disaster response.

Intellectual resilience is bolstered by the very act of learning and practicing the skills which you have learned.  It is as we gain experience and knowledge we slowly imprint new patterns which we may later use to compare and ultimately recognize as familiar situations and events that unfold during an event.  The more of these patterns that we have in our intellectual canteen the more quickly we can recognize and adapt to the ever changing disaster environment.  Just as we learn the patterns of a heartbeat or the patterns of respiration we can learn the many patterns that exist within medicine, patterns which occur more frequently and more rapidly but are no different when they occur during a disaster event.  When we can recognize these patterns quickly we can respond quickly thus bolstering our intellectual resilience.

Relationship resilience bolsters our social functioning.  It is through our relationships with those that we hold dear, spouses and significant others; children and grandchildren; parents; relatives; friends; coworkers that we fill our canteen of relationship resilience with memories and comforting mental images that carry us through our times of separation.  It is also these relationships that safeguard our lives and our emotions.  Disaster response is a high-risk sport not unlike scuba diving and for that reason requires that you have a buddy to check on you and ensure that you are not becoming overwhelmed, ensure that none of your canteens of resilience are running dry.  It is through these relationships that we not only fill our canteens but keep them full and keep watch on each other.

Functional resilience bolsters our behavioral function.  The skills that we have practiced in our day-to-day lives as we have moved through our careers are that with which we fill our canteen of functional resilience.  Like the patterns in our canteen of intellectual resilience the skills of our functional resilience are no different at times of disaster response than they are at times between disasters.  We need only be able to access those skills more quickly and perform them more calmly.

Spiritual resilience is somewhat different because the canteen of spiritual resilience is not filled by what we believe, but rather by the fact that we believe.  Research in the area of resilience has shown that the very act of believing enforces an even intelligence beyond ourselves, a higher purpose for higher power, bolsters our resilience, improves our function and our likelihood to master adversity.

It is through the maintenance and enhancement of resilience both for each individual healthcare professional as well as for the processes by which we provide high acuity healthcare in the intensive care unit and other areas of the hospital that we maximize the surge capacity of these most critical areas as well as ensuring that those that staff them do not become the collateral casualties of our disaster response.

When Worlds Collide

John, a veteran of the Fire Department of New York had “retired” to his southeastern home several years ago. Unable to sit and fish all day, John soon joined the county fire service and became a resource for his department and his community. Loved by everyone for his jovial nature John was admired by the rookie firefighters.

One bright summer day, a chemical tanker truck caught fire in front of the regional trauma center. The trauma center was upwind and in no direct danger when fire and hazmat teams arrived. The fire was quickly contained and the hazmat team set about the work of clean-up.

As operations began, John’s first duty was to establish contact and coordination with the hospital. Smiling he turned to the rookie assigned to him for training and said,

“This will be fun, watch their reaction when we ask to speak with their Liaison Officer. They won’t have a clue what I’m talking about.”

John and the rookie walked into the hospital still smiling and asked the security officer at the front door to contact the Liaison Officer. Much to John’s surprise, the security officer immediate called for the Liaison Officer to come to the front lobby. Moments later, a young woman arrived and introduced herself to John.

Unfortunately, John’s experience is still the exception rather than the rule when community response services interact with hospital services. Too often these interactions are seen as either a threat to hospital autonomy or as a public relations exercise. As with most problems of culture and communication, the fault lies on both sides of the relationship.

Hospitals are for the most part private businesses with the duel mission of providing care and delivering a profit. Unfunded mandates and social pressures have created a complex web of regulation and oversight that is largely resented by those in the healthcare professions. Any aspect of the business that is not regulated is seen as an opportunity to distinguish oneself from the competition and is thus jealously protected. Until this year, that included hospital command structure during a disaster.

Fire/Rescue has been steeped in a system of command and control born of the need to ensure that lives and property are not placed at undue risk. Unlike healthcare professionals, Fire/Rescue professionals know that a breakdown in command decision making will cost their life or the life of one of their colleagues. There is no room for individuality or customization of the system in the mind of the Fire/Rescue professional.

These worlds collide in the modern era of disaster preparation and response. By mandate, hospitals and healthcare facilities are now required to use the same incident command system that Fire/Rescue has used for decades. The relationship is further complicated by the fact that this mandate reverses the traditional lines of authority and knowledge in which Fire/Rescue has always taken instruction and guidance from healthcare as regards Fire/Rescue’s medical operations. Now healthcare must take instruction and guidance from Fire/Rescue.

As with any realignment of a relationship, the integration of hospitals and healthcare institutions with the larger community response will ultimately strengthen the system and the nation’s preparedness. Until then professionals on both sides will do their best when their worlds collide.

Qui Tam - Sarbanes Oxley & Disaster Preparedness

Healthcare is a business and fortunately most involved in the business of healthcare are ethical and moral people. To be sure, there are some who commit fraud and steal from the system. Many are caught and suffer civil and criminal penalties for their deliberate actions, and many more get away with fraud longer than they should.

Corporate business people are also mostly moral people. Unfortunately, the media attention to corporate fraud has lead to the proliferation of Qui Tam law suits and regulations such as Sarbanes Oxley. These worlds overlapped this year when Disaster Preparedness guidelines, corporate financial forecasts, the signatory obligations imposed by the National Response Plan (NRP) and the mandates of the National Incident Management System (NIMS) collided.

Last year a High Alert, LLC white paper had raised the specter of NRP/NIMS compliance being linked to CMS (Medicare, Medicaid and Tricare) billing, the discussion had been strictly theoretical. Several federally funded training programs have now brought to the table a new and ominous implication of the NIMS Integration Center Implementation Plan for Hospitals and Healthcare. Additionally, hospitals have reported being informed that disaster preparedness will be linked to CMS reimbursement (Medicare, Medicaid and Tricare payments). The white paper is available for download here:

Download cost_of_disaster_unpreparednessrevised_23apr07.pdf

This is the first step in a progression that, if followed by CMS, Department of Health and Human Services (DHHS), Department of Homeland Security (DHS) and Department of Justice (DoJ), will put the full weight and power of the federal government behind an unfunded mandate for hospital preparedness. An appreciation how CMS and DoJ have handled dealt with healthcare providers who have run afoul of these agencies in the past 18 months may portend the future.

In early 2006, DoJ instituted a change in how it dealt with Medicare, Medicaid and Tricare fraud. In prior years, these issues were typically dealt with as civil issues with civil penalties and restitution. Most offenders plead "guilty" or "no contest" to the charges, paid a fine and went home. Beginning in early 2006, DoJ began using the "guilty" plea from the civil cases as evidence to prosecute these individuals criminally. The type of insurance fraud spanned the gambit from billing for nonexistent patients to billing more than the documentation would support. It is this latter prosecution that is the cause of concern.

NRP and NIMS regulations are promulgated upon all signatories to NRP/NIMS, including DHHS. As signatories, all government agencies agree to promulgate the requirements of NRP/NIMS upon all their agencies/departments. Since DHHS is a signatory, this would include CMS (Medicare, Medicaid, Tricare). Since a all healthcare providers who bill CMS directly or indirectly are regulated by CMS and have independent contractor status with CMS, the requirements and regulations promulgated upon CMS by NRP/NIMS through DHHS are passed down to those contractors. This is affirmed by every healthcare provider every time they bill CMS on a UB92, CMS1500 or electronic equivalent because these forms include the attestation that the healthcare provider is in compliance with all regulations and requirements of CMS and the program billed.

It is this last fact that opens the door for DoJ to involve itself in hospital preparedness. Through their actions in 2006, DoJ has shown the willingness to criminally prosecute healthcare providers for overt insurance fraud. Signing the CMS attestation when not in compliance with NRP/NIMS is the same as signing the attestation that chart documentation is in compliance with CMS documentation standards. In short, the failure to be all hazards prepared may have just been raised to the level of a federal felony, enter Qui Tam.

Qui Tam is a provision of the False Claims Act, which allows for a whistleblower to bring a lawsuit on behalf of the United States, where the whistleblower has information that a Medicare/Medicaid provider has knowingly submitted or caused the submission of false or fraudulent claims. The False Claims Act provides incentive to whistleblowers by granting them between 15% and 30% of any award or settlement amount. In addition, the statute provides an award of the whistleblower's attorney's fees.

Once a whistleblower brings suit on behalf of the government, the United States Attorney for the district has the option to take over the case. If the US Attorney does so, the government will usually notify the Medicare/Medicaid provider being sued that a claim has been filed. Qui Tam actions are filed under seal, which has to be partially lifted by the court to allow this type of disclosure. The seal prohibits the defendant from disclosing even the mere existence of the case to anyone, including its shareholders. The government may then, without disclosing the identity of the whistleblower or any of the facts, begin taking discovery from the defendant.

Claims that are falsely presented to the Government for payment are actionable under the False Claims Act. The False Claims Act covers a Medicare/Medicaid provider who:

• Knowingly presented or caused to be presented a false or fraudulent claim for payment or approval to an officer or employee of the government;
• Knowingly made, used, or caused to be made or used, a false record or statement to get a false or fraudulent claim paid by the government;
• Conspired to defraud the government by getting a false or fraudulent claim allowed or paid;
• Knowingly made, used or caused to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government, ("reverse false claim").

A hospital or healthcare facility which fails to fully implement an NRP/NIMS Compliant “All Hazards” Disaster Preparedness program and continues to submit Medicare/Medicaid claims including the attestation that the provider is in compliance with all regulations and requirements of CMS and the program billed presents or causes to be presented a false claim. A claim is "knowingly" made if:

• There is actual knowledge of a false claim
• Deliberate indifference to the truth or falsity of a claim
• Reckless disregard of the truth or falsity of a claim

The implications for the corporate officers of a hospital go beyond just CMS fraud, civil penalties and imprisonment. Hospitals are now largely operated by public entities and thus file financial forecasts and financial statements. These forecasts are based on projected CMS reimbursements. If a facility is not NRP/NIMS compliant and “All Hazards” disaster prepared, the corporate officers are not only in danger of CMS fraud, but of projecting CMS reimbursements they know are not collectable. Further, the seal on a Qui Tam claim prohibits the defendant from disclosing even the mere existence of the case to anyone, including its shareholders a fact which is in conflict with the provider's obligation under Security and Exchange Commission regulations that require disclosure of lawsuits that could materially affect stock prices, enter Sarbanes-Oxley.

The Sarbanes-Oxley Act came into force in July 2002 and introduced major changes to the regulation of corporate governance and financial practice. It is named after Senator Paul Sarbanes and Representative Michael Oxley, who were its main architects, and it set a number of non-negotiable deadlines for compliance. Periodic statutory financial reports are to include certifications that:

• The signing officers have reviewed the report
• The report does not contain any material untrue statements or material omission or be considered misleading
• The financial statements and related information fairly present the financial condition and the results in all material respects
• The signing officers are responsible for internal controls and have evaluated these internal controls within the previous ninety days and have reported on their findings
• A list of all deficiencies in the internal controls and information on any fraud that involves employees who are involved with internal activities
• Any significant changes in internal controls or related factors that could have a negative impact on the internal controls

Sarbanes-Oxley establishes an independent commission which is required to study and report on the extent of off-balance transactions. The commission is also required to determine whether generally accepted accounting principals or other regulations result in open and meaningful reporting.

Financial statements published by regulated companies are required to be accurate and presented in a manner that does not contain incorrect statements. These financial statements must include all material off-balance sheet liabilities, obligations or transactions. Regulated companies are required to publish information in their annual reports concerning the scope and adequacy of the internal control structure and procedures for financial reporting. This statement must assess the effectiveness of such internal controls and procedures. A registered accounting firm must, in the same report, attest to and report on the assessment on the effectiveness of the internal control structure and procedures for financial reporting. Regulated companies are required to disclose to the public, on an urgent basis, information on material changes in their financial condition or operations. These disclosures are to be presented in terms that are easy to understand supported by trend and qualitative information of graphic presentations as appropriate.

Sarbanes-Oxley imposes penalties of fines and/or up to 20 years imprisonment for altering, destroying, mutilating, concealing, falsifying records, documents or tangible objects with the intent to obstruct, impede or influence a legal investigation. The legislation also imposes penalties of fines and/or imprisonment up to 10 years on any accountant who knowingly and willfully violates the requirements of maintenance of all audit or review papers for a period of 5 years. Organizations may not attempt to avoid these requirements by reincorporating their activities or transferring their activities outside of the United States.

Disaster preparedness is no longer just an accreditation issue. “All Hazards” disaster planning is no longer just a requirement of qualifying for federal grants. Education is no longer a last priority. Disaster planning, preparation and education are the newest legal shield for the healthcare corporate officer.

The Unprepared Beware.

Volunteering in Times of Disaster - The Time is Now

Physicians come to their profession with a high sense of personal honor and a high sense of personal duty.  It is these two characteristics that spur physicians to contribute time, energy, talent and resources in times of local, regional or even national disaster. 

Whether hurricane Andrew, hurricane Charlie, hurricane Katrina, hurricane Rita, hurricane Wilma, the terrorist attacks on the Murrah federal building, the World Trade Centers or the Pentagon, whether forest fires or large automobile accidents whenever the healthcare system appears to be overwhelmed physicians and other health care professionals find themselves spurred to action.  Unfortunately they also find themselves spurred. 

It seems senseless whether the time of tremendous need physicians would be turned away from such places as Louisiana, Gulfport Mississippi, Port Charlotte, Florida, Oklahoma City, New York City and Washington D.C.  Yet a small understanding of how disaster response systems work explains this phenomenon. 

The first and most important thing that physicians and other health care providers must know is that if you are not part of a disaster plan, you are not part of a disaster response.  Even though it may seem chaotic when disaster relief professionals are working side by side with volunteers and bystanders to save lives and livelihoods, what you are actually witnessing is a wellchoreographed dance.  Long before the disaster struck plans were established on how best to respond in the event of a disaster.  It is in this planning phase that the use of volunteers whether lay persons or health care professionals is anticipated and integrated. 

Therefore if you wish to be part of a response, if you wish your valuable skills to be used to help stave off disaster and prevent catastrophe the time to volunteer is now. 

What Is The Disaster Life Cycle?

Disasters come in four phases:

• Interphase
• Adverse Event
• Response Phase
• Recovery Phase

With respect to most disasters we hope that interphase, that period between disasters, is the longest period of time.  It is during interphase that plans are reviewed, practiced, refined and practiced again.  It is during this period of time that it is most optimal for health care professionals to join the ranks of volunteers to be called upon when the disaster strikes. 

The Adverse Event is that brief moment in time when the disaster actually occurs.  When the levy actually breaks, the hurricane passes directly overhead or the bomb blasts. This discrete moment is defined by the event itself. There is little that responders can do except survive to lend aid when the event has past. Adverse Events cannot be prevented, but can be mitigated.  They will happen with little regard to what planning has or has not occurred.  Occasionally man made events can be preventive but by and large the event phase is inevitable. 

Immediately following the event begins the response phase.  It is this acute period that determines whether an event becomes a disaster.  Disaster is defined as need exceeding resource.  If during the interphase weaknesses in resource management, procedures or processes are identified such that needs never exceed resources, the event never becomes a disaster. Unfortunately, this occurs in precious few events.

It is in the response phase that defines whether a disaster goes on to be a catastrophe.  While a disaster is when needs exceed resources, a catastrophe is when needs excess all ability to respond.  When the response phase fails or the planning phase is found lacking catastrophe includes. 

Medical Reserve Corps – Your Chance to Serve

The Medical Reserve Corps (MRC) program was launched officially as a national, community-based movement in July 2002. It was formed in response to President Bush’s call for all Americans to offer volunteer service in their communities. The objective of the MRC program is to strengthen communities by establishing a system for medical and public health volunteers to offer their expertise throughout the year and during times of community need. More than just a corps of available healthcare professionals, the MRC is a full partner of the White House’s USA Freedom Corps and the Department of Homeland Security’s Citizen Corps.

Volunteerism for America’s healthcare providers has faced many obstacles in the days before the MRC. Issues of liability insurance, malpractice, worker’s compensation, injury insurance and many other serious concerns have plagued the medial volunteer effort in the United States for the past 2 decades. If insurance issues did not stand in the way of medical volunteers, licensure and accreditation issues stymied efforts to provide much needed disaster medicine services following disasters. 

The adoption of Emergency Medical Assistance Compacts (EMAC) across all 50 states and all United States territories was designed to address the majority of these concerns, but recent legislation introduced in congress shows that the EMAC’s are far from resolving the key insurance issues facing medical volunteers. Legislation is pending before both the U.S. House of Representative and the U.S. Senate to resolve the interstate worker’s compensation issue for healthcare providers who volunteer their services in time of disaster. In the near future, similar legislation will be proposed to resolve malpractice coverage issues for healthcare volunteers in disaster.

Membership in the Medical Reserve Corps resolves all these problems now and without the need for special legislation. Medical Reserve Corps volunteers are credentialed and their membership in the MRC provides Eminent Domain coverage for malpractice as well as volunteer injury coverage in the event of an on duty mishap.

Who Can Volunteer for the Medical Reserve Corps?
MRC volunteers may include medical and public health professionals including:

• Physicians
• Nurses
• Pharmacists
• Emergency medical technicians
• Dentists
• Veterinarians
• Epidemiologists
• Infectious disease specialists.

In addition, volunteer interpreters, chaplains, amateur radio operators, logistics experts, legal advisors, and others may fill key support positions.
Most MRC response and recovery assignments are secured through local and state channels. However, opportunities for MRC volunteers to assist outside their local jurisdiction do arise. During the 2004 hurricane season, MRC volunteers were asked to support the American Red Cross (ARC) response activities in Florida. This was the first deployment of MRC volunteers outside of their local jurisdiction.

During the 2005 hurricane season, the MRC strengthened its partnership with the ARC. Prior to Hurricane Katrina's landfall, the ARC disaster operations staff requested MRC support for their sheltering operations. Policies and processes were developed to identify, assign, and activate MRC members willing, able, and authorized to respond. ARC provided transportation, logistical support, and supervision for the deployed MRC members who supported ARC health services and mental health and shelter operations.
MRC members also participated in response activities outside of their local/state jurisdiction through a mission to support HHS response and recovery efforts.

The first Federal activation of MRC volunteers occurred on September 15, 2005, when HHS needed staffing support for three special needs shelters in Louisiana. Subsequent mission assignments allowed MRC members to fill positions in Community Health Centers and health clinics on cruise ships housing evacuees in Mississippi and to perform health assessments in Texas.

For more information about the Medical Reserve Corps or to become a member, please visit the MRC website at www.medicalreservecorps.gov, or contact the Medical Reserve Corps at:

MRC Program Office
Office of the U.S. Surgeon General U.S. Department of Health and Human Services
5600 Fishers Lane, Room 18C-14
Rockville, MD 20857
Tel: (301) 443-4951
Fax: (301) 480-1163
E-mail: MRCcontact@hhs.gov

The National Disaster Medical System – NDMS the Nation’s Medical Ready Force

The National Disaster Medical System (NDMS) is a federally coordinated system that augments the Nation's medical response capability.  The overall purpose of the NDMS is to establish a single integrated National medical response capability for assisting state and local authorities in dealing with the medical impacts of major peacetime disasters and to provide support to the military and the Department of Veterans Affairs medical systems in caring for casualties evacuated back to the U.S. from overseas armed conventional conflicts.

The National Response Plan utilizes the National Disaster Medical System (NDMS), as part of the Department of Health and Human Services, Office of Preparedness and Response, under Emergency Support Function #8 (ESF #8), Health and Medical Care, to support Federal agencies in the management and coordination of the federal medical response to major emergencies and federally declared disasters.

Much like Army Reservists, NDMS members are volunteers who become government employees when they are deployed and must commit to two weeks service if called.
NDMS teams are essentially designed to be a rapid-response element that deploys to disaster sites with sufficient supplies and equipment to sustain themselves and care for patients for a period of 72 hours. In mass casualty incidents, their responsibilities include triaging patients, providing austere medical care, and preparing patients for evacuation.

In other types of situations, NDMS teams may provide primary health care and/or may serve to augment local health care staffs. Should disaster victims need to be evacuated to a different locale to receive more definitive medical care, NDMS teams may also be activated to support patient packaging, transport, reception and disposition.

The units are supported by a cadre of administrative, logistical, and communications personnel whose roles are vital to successful deployment. Medical members are required to maintain appropriate certifications and licensure within their discipline. When members are activated as intermittent Federal employees, licensure and certification is recognized by all States.

In contrast to MRC members, as Federal employees, all NDMS team members are paid while serving.

NDMS medical personnel includes many disciplines from physicians to pharmacists, ARNP’s and PA’s. The NDMS teams are also replete with an experienced pool of healthcare talent with diverse medical backgrounds, ranging from RN’s and LPN’s to Nurses Assistants. Paramedics and EMT’s, with years of training and daily emergency experience are also an integral part of the teams. Respiratory therapists bring yet another medical specialty to help round out the deep medical resources of an NDMS team.

Administrative, Logistical and Communications experts round out an NDMS team and ensure that a fully self sufficient group of professionals is ready to deploy at a moment’s notice when requested by federal disaster declaration.

Most NDMS teams are also state disaster medical response teams providing reservist style medical support for their local communities as a supplement to MRC assets in an area.

For more information about the National Disaster Medical System or to become a member, please visit the NDMS website at http://www.oep-ndms.dhhs.gov.

So How Do I Participate?

First, get educated. The sad truth is that few physicians have spent even eight hours learning how to keep themselves, their families and their patients alive in the event of a disaster. Take a Basic Disaster Life Support Course or similar Healthcare First Receiver training. You are of no use to anyone if you fail to go home alive at the end of the day.

Next, get involved. Of the over 5000 hospitals in the United States, only a very small fraction have physicians on the hospital disaster planning committee. Of greater concern is that few if any of those physicians who do participate in hospital disaster planning have any formal training or certification in disaster medicine or disaster management.

Once you are educated and involved, become a resource. The 2006 Institute of Medicine reports on the state of emergency medicine in the United States soundly rebuked hospitals and healthcare in general for poor and ineffective planning, preparedness, training and practice. Throughout the evolution of healthcare disaster preparedness, physicians have been conspicuously absent from the table. It is well past time that those who have the ultimate responsibility for patient care and well being take responsibility for their role in disaster planning and preparation.

Finally once you have become educated, involved and a resource, volunteer. If you are fortunate enough to have a career which allows you the freedom to deploy for weeks at a time to locations far from home, consider becoming a member of an NDMS team. If your career needs and practice responsibilities require that you stay closer to home, join an MRC team in your area. Either way you will serve your community, your nation and your fellow man in a way not possible anywhere else in medicine.

The Other Side of The Stethescope

Dr. John Ruiz recently suffered a bit of culture shock. In his professional life Dr. Ruiz was a New York City physician on the cutting edge of detection and treatment of malignant melanoma, the most serious form of skin cancer.  He had recently flown to Florida to visit family hospitalized there and had entered the hospital unchallenged without even identifying himself when he entered the intensive care unit in Orlando’s most prominent hospital. In Florida he had seen children running up and down the hospital halls and family visiting anytime they chose. Far from strictly enforced, in Florida families challenged the authority of nurses and doctors to restrict visitation even to allow for patient recovery. Further, Dr. Ruiz had seen nurses publicly reprimanded by supervisors for enforcing visitation policies in Florida. He was seeing that the “All Hazards” preparedness and Situationally Sensitive Security to which he was accustomed to was far from universal.

A year earlier, at age 39, Dr. Ruiz suffered a heart attack while working in New York City. Like so many heart attacks in the north, his began while shoveling snow and ended on the operating table. Owing to his young age and the fact that he exercised daily, he did well and went home. His story would have ended there except Dr. Ruiz realized there was a stark difference between his reality and the state of healthcare safety in the rest of the nation.

Dr. Ruiz had always been one of those doctors who never saw the need for increased disaster preparedness for healthcare. Practicing in New York City after 9/11 it seemed to him that every hospital and healthcare facility had instituted “Situationally Sensitive Security” and “All Hazards” Disaster Plans. Despite the fact that he had family and friends involved in national preparedness he had always assumed that every facility was as ready as the ones where he worked.

Prior to his heart attack, Dr. Ruiz had never walked in the front door of the hospital. When he arrived as a patient, he entered the front door and was immediately asked for photo id. He showed his driver’s license and his wife was immediately stopped and asked for her id. For the first time he saw that no one entered the hospital without scrutiny and business at the hospital. This was such a contrast to what he now saw in Florida. Could it be that the rest of the nation was this unsafe?

Once admitted to the hospital, Dr. Ruiz learned that visiting hours were not only defined and restricted, but strictly enforced. Moreover, small children such as his own could not visit on the patient floor; he would have to be well enough to visit with them in the family spaces. What a difference from the world he now saw! How do the doctors and nurses work in such a place?

When Dr. Ruiz returned home he decided to see if his perceptions were in fact correct. He again entered through the front door. Had it not been for his hospital id, he would not have gotten in. He learned that on this day there had been an incident at another hospital and the hospital had increased the level of security. For the first time he took note of the attitude and decorum of his own patient’s visitors. In sharp contrast to what he had seen in Florida, these New York visitors listened to instructions, obeyed visitor policies and followed the instructions of the nurses.

The Safe Work Environment

What Dr. Ruiz came to realize is what preparedness experts have been saying for years; healthcare has few well prepared institutions while the majority of healthcare has chosen to ignore the threats and the most obvious solutions.

The most important change is to incorporate security and preparedness into the daily regimen of every hospital function and every hospital employee. The Situationally Sensitive Security Dr. Ruiz encountered in his hospital ensures that the hospital staff as well as all visitors are accustomed to some level of scrutiny when entering the hospital. At the lowest levels, no more that an id check occurs, but as security concerns increase, the level of scrutiny and restriction increase. This type of daily routine ensures that when increased security is required, the baseline behaviors are in place and familiar. The same philosophy is the basis of Continuous Integrated Triage and several other “All Hazards” protocols.

Workplace safety has become as much a component of “All Hazards” preparedness and patient safety initiatives. Facilities that have instituted this expanded approach to preparedness have found that patient safety initiative, employee safety programs and “All Hazards” preparedness are a natural combination. Funding once used for just one program can be applied to all three areas simultaneously thus allowing a hospital or healthcare institution to benefit in all three realms for each dollar spent.

More importantly, Dr. Ruiz inadvertently identified the reason that many preparedness experts have failed to successfully persuade hospital and healthcare decision makers to spend money on preparedness. Like Dr. Ruiz, many of these experts practice in places where most of the preparedness lessons have been not only observed, but learned and acted on. These experts are assuming that those practicing across the rest of the nation have already made the changes found in communities like New York City. The sad reality is that the vast majority of the nation has not made these changes. The only question is what will it take for the majority of hospitals and healthcare institutions to make these changes.