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Mass Casualty Care: Overlooked Community Resources (continued)

Cindy DiBiasi: Well, thank you, Debra, and thank you to all of our presenters. And as I said, we will be coming back to you in a few minutes. And I'm sure our discussion with the panelists have given our audience a lot to think about, and we are anxious to hear your questions.

But before we move into our question-and-answer session, I'd like to make you aware of the various tools AHRQ has assembled to help communities respond to bioterrorism and other public health emergencies. For a selective list of those tools, you can go to the Web site shown on your screen.

You may also click on the additional information tab in the lower right-hand side of your screen, and here you'll find a link to the resource page for today's Web conference. For those of you listening on the phone, the Web site is

And before we get to your questions, I have another poll question for the audience. The question is how many of you are looking at using any of the facilities mentioned by our panelists, nursing homes, primary care centers, or former hospitals in your preparedness plans?

Please select the poll tab to answer this question. Again, the question is, "How many of you are looking at using any of the facilities mentioned by our panelists, nursing homes, primary care centers, or former hospitals in your preparedness plans?"

And we'll be waiting on the results of those, and we'll get back to them as soon as they come in, but I wanted to let you know that the phone lines and E-mail are now open, and let me give you a few instructions on how to ask your question. So, if you're listening to this program on the phone, press Star 1 to let us know you have a question. An operator will assist you.

If you are listening to this program through your computer, please click the "Email a Question" tab in the lower right-hand corner of your screen, type your question in the space provided, and click "Send."

As you formulate your questions or queue up on the phone lines, I'd like to say a few words about our sponsors. The mission of AHRQ is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

The agency supports the work of health services researchers at the Nation's leading academic centers through extramural grants and contracts and maintains a rigorous intramural research program that collects and analyzes data to understand changes in health care quality, cost, use, and access.

AHRQ also supports efforts to develop the tools and information used by the public and private sectors to measure and improve health care quality. That research is part of AHRQ's comprehensive bioterrorism preparedness research program.

And I'd like to thank the director of the program, Dr. Sally Phillips, for her leadership in producing this Web conference. AHRQ hopes that today's Web conference and previous events will provide a forum for a productive discussion between policymakers and researchers on these issues.

And now we're getting the results of the last poll in real time. We have 78 percent said yes and 22 percent no. And I'd like to just repeat that question.

The question was, "How many of you are looking at using any of the facilities mentioned by our panelists, nursing homes, primary care centers, or former hospitals in your preparedness plans?"

And so 78 percent of the people on the call today are planning on doing that. Is that a surprise to any of you, or did you expect that high a number?

Lucy Savitz: Well, I think Andrea made the point earlier that 78 percent of the people respond positively but we're not sure how heterogeneous or homogeneous that response is. So is it mostly nursing homes, mostly former hospitals, mostly primary care? We really don't know the answer to that.

Cindy DiBiasi: Hopefully we can find that out today as the audience starts to call in. If you're listening on the phone—I'm sorry, rather, excuse me—so we're going to start our question and answer period, and we have a question for Lucy, and I'm going to read it off the monitor.

The question is, "Do we really want to send people who are sick or infected with something from an attack or pandemic to a nursing home, where the population is particularly susceptible or vulnerable to diseases?" And this comes from Mike Riebel, of Bear River Health Department in Utah.

Lucy Savitz: Thank you for that question, Mike. I would say that we're not—nobody's really envisioning sending sick patients who've been hurt in the event to the nursing home. So let me begin there.

What we're talking about: are there former nursing home patients who are currently in a hospital that could be stabilized and returned to the facility where they were residents? Are there community-dwelling elderly or people with chronic diseases who would need temporary respite care and you could move them into a nursing home facility?

And again, it's very localized. Some nursing homes would have capacity to accept patients like this. I cited the study that was published in the American Journal of Public Health in August 2004, and they found that after the earthquake in Los Angeles County, 52 percent of the nursing homes received disaster-related admissions.

About a third of those were not former residents of their facility. So there is a need in the community. These would not be necessarily infectious patients but patients who couldn't be cared for in the hospitals that were treating those patients who had been injured in the event.

Cindy DiBiasi: And we have a phone call, and on the line is Jeanine from Texas. Hello.

Caller: Hi. This is Dr. Edwards. And our question is for Dr. Berg. Thanks to all the panelists for a stimulating discussion. Dr. Berg, your findings are very similar to ours, and the question is how do you get the primary care folks to the table? Do you use a stick? Do you use a carrot? What's the secret?

Cindy DiBiasi: Okay, Dr. Berg. What is your power of persuasion?

Debra Berg: Our charm and wit. That's a very good question and one that we were challenged with. And we worked, first of all, with the senior leader administration, with the CEOs of the primary care centers, and we made sure that no matter what we did in the primary care centers, that the CEOs were always invited to attend either one of our learning sessions or one of the feedback sessions where the centers were able to participate and provide information on what they've done over the course of a month.

In addition, there's nothing like real-life experience. Unfortunately, primary care centers have been up against a lot during September 11th, the anthrax investigations, the power outage the far rockaway airline crash. So there was a sense that primary care centers needed to do something.

But when we started with the assessment, it became clear to all of us that what it was that primary care centers needed to do was defined and there was a clear interest on the part of the primary care centers to do so.

Lastly, I'll just finish by saying that we tried to be as interactive as possible, and that came with certain perks. So when we did our needs assessment, we did it on site.

And with that came subject matter experts that were really able to give an onsite technical consultation to the primary care centers.

The primary care centers were able to become a part of the health alert network, so they now receive the same health alerts and advisories that the hospitals receive, and they got a seat at the Emergency Operations Centers so that if there is an emergency in New York City at the Office of Emergency Management there will be representation for primary care centers.

So the perks do not come in the sense of dollars and cents, but it really came in the way of real emergency preparedness enhancements.

Cindy DiBiasi: Did that answer your question? Hello?

Caller: Yes. That's excellent.

Cindy DiBiasi: And thank you for calling. And now we have a question by E-mail for Andrea, and the question is, "Could a shuttered hospital be used for isolation and quarantine?"

Andrea Hassol: Our sense was that it possibly could be. Some hospitals are located so that they're not in the midst of a heavily populated area; they're a little bit removed. The perimeter needs to be secured, so we had some security specialists looking at how quickly and how readily could you secure a perimeter. One of the issues might be that the local town would not want the isolation or quarantine facility and you'd have a security issue if they tried to prevent that kind of use of a facility.

So there certainly are things to consider if you're going to rely on a shuttered hospital for these purposes. But again, advanced planning can go a long way toward making it possible to use a shuttered facility even as a quarantine facility.

Cindy DiBiasi: Okay. And another question for you or for Dr. Zane, or you can both weigh in on this one. And this comes from Karen Harvest. She wants to know who in most States would know the location of shuttered facilities. Local health departments? State health departments?

Andrea Hassol: Well, in the case of Massachusetts, it was the State Hospital Association. They had a listing of all the hospitals that had closed. The Centers for Medicare and Medicaid Services know about hospitals that have closed but may not know what's become of them.

Many hospitals quickly are turned over into nursing homes or assisted living or other purposes, while others stand largely vacant for a number of years, and it's kind of a moving target; at any time, they may have another mission or be sold for development.

So you have to find out which are the ones that have closed in recent years and then get on the phone and call them and find out what the current status is, who owns them, what the plans are for the place, and see what your options are.

Cindy DiBiasi: Dr. Zane, would you lake to weigh in on this?

Richard Zane: Yes. And also most States have a department of public health, where hospitals have to report whether they are going to be closing or not. And most departments of public health, as part of keeping track of essential services, will have at some point been informed that a hospital has been closed.

Cindy DiBiasi: Okay. Question for Lucy. Nursing homes typically have limited RN/LPN staff. Has the evaluation of these resources included the availability of qualified staff to support the bed capacity?

Lucy Savitz: This is an important question, and thank you for asking this. In our focus groups, as I mentioned, we're talking with administrators and nursing home's medical directors and disaster coordinator's and staffing continually comes up in a variety of capacities.

We understand that there are limited staffing. And it's interesting that nursing homes out of experience with natural disasters have created plans for keeping staff there, for picking up staff in bad weather situations, in hurricane situations in North Carolina, for example.

The other issue that's important to think about here is the extent to which there are State regulations that may even further constrain staff availability.

For instance, in North Carolina, if a state of emergency is declared, it's not clear to the nursing home administrators whether or not nurse staffing hour limitations would also be waived at that time, and so there are questions about how long could pre-existing staff on site work in a given shift in meeting the demands.

So I think these are very interesting points to think about. And we do know the nursing homes have said that, particularly for elderly patients with Alzheimer's and other patients, in chaotic times they need personal comforting. And so that would require additional staff as well above and beyond normal functioning.

Cindy DiBiasi: We have a caller. Susan in Florida is on the line. Hello.

Caller: Hi. This is Susan Skelton with the Florida Senate Domestic Security Committee. My first question is for Dr. Savitz, and it relates to how the nursing homes and the hospitals coordinate in the plan.

We had, of course, four major hurricanes in Florida last year, and unfortunately we had a problem with the nursing homes actually evacuating their patients to the hospitals and trying to use the hospitals as special need shelters.

And I just wondered if in this discussion there was a coordinating effort between hospitals and nursing homes in the particular geographic areas, and I have a followup question to Dr. Berg related to Medical Reserve Corps.

Cindy DiBiasi: Okay. Let's let Lucy answer the first question and then we'll get back to you.

Lucy Savitz: I think this is an important issue. And the real purpose of our atlas, for instance, is to stimulate these sorts of discussions related to coordinated planning. In the focus groups that we've conducted, there's not been coordination discussions that have occurred between hospitals and nursing homes, between State agencies, local agencies.

We do know an important player, though, that nursing homes look to rely on through their disaster plans is the Red Cross, and I think that's one that I didn't mention earlier, Red Cross is an important player in these local communities and how they're being viewed in that equation. So we're hoping that the results of our study will help stimulate these kinds of discussions to prevent the situation that you experienced in Florida.

Cindy DiBiasi: And you have a followup question for Debra, I believe?

Caller: Yes. Just real quickly back to Lucy, y'all might want to take a look at the Department of Health Special Needs After Action Report here in Florida, because I think they addressed some of these issues as well.

Lucy Savitz: Thank you.

Caller: Dr. Berg, on the Medical Reserve Corps, is there a template that you all are using or is there some type of guidance formula that could be used for States to look at in implementing the Medical Reserve Corps?

Debra Berg: Well, presently, we've been recruiting individuals in the Medical Reserve Corps from around the city, and I could refer you to the individual that's responsible for organizing those volunteers. Presently, we have about 3,500 retired and working health care workers that have signed up for the Medical Reserve Corps.

Let me make one comment about the Medical Reserve Corps. We state very clearly in the literature that for any health care worker that's actively working, their first responsibility is to their health care facility, whether it be a hospital, a nursing home, or a primary care center.

However, there may be times when a health care worker cannot get to their site of work geographically, and there may be a point of distribution that's set up in their neighborhood.

If they're part of the Medical Reserve Corps and they've been part of the trainings that have gone along with Medical Reserve Corps, in fact they are willing volunteers and very helpful to the process that's occurring in a citywide emergency. So the Medical Reserve Corps has been very active in New York City.

It's been a labor of love by Henry Cuso, who's in the Bureau of Emergency Management in the New York City Department of Health, and I will be glad to send you that information following this conference.

Caller: Great. Thank you very much.

Cindy DiBiasi: That answers your question?

Caller: Yes. Thank you.

Cindy DiBiasi: Thank you. We have a question for Andrea and Richard. Has anyone looked into the medical and legal issues surrounding the movement of a patient from a hospital to a lower level of care that would be provided at an alternate care site?

Richard Zane: We certainly have asked the question and looked into what legal ramifications there may be or constraints. And currently there are a number of laws, both State and Federal, which define how and when and why patients should or should not be transferred.

Mainly it's EMTALA, the Emergency Medical Treatment and Labor Act, that addresses how patients should or shouldn't be treated and transferred. And we are currently asking CMS to give us guidance on how such a shuttered hospital could or couldn't be used when patients need to be transferred.

Cindy DiBiasi: Andrea, would you like to add to that?

Andrea Hassol: Yeah, we realize that there are a lot of regulatory and legal issues around the whole idea of the shuttered hospital, not just the movements of patients and whether they consent to transfer, but a myriad of issues that arise from who's going to maintain the medical records for years after the facility closes, just all kinds of things.

We took a look at the Federal regulations and the medical conditions of participation. We also took a look at four States' regulations to see how variable they were. We were expecting to see very different regulatory climates in Massachusetts and Texas and Kansas and Illinois. We did see some differences, but there were also a lot of consistencies.

And I think the issue is working through the issues in advance, figuring out how on an emergency basis to waive some of the regulations that would be barriers, and who would have to declare an emergency in order to be able to waive regulations at the State level.

Some States may already have legislation that allows the health department to waive licensure kinds of regulations or to speed up the licensure process for a facility that will be reopened in a surge mass casualty event.

Others may not have that kind of legislation, and maybe they should consider writing that kind of legislation in advance so that, should an event occur, they'll be prepared.

Cindy DiBiasi: A question for Debra Berg by E-mail. Can you gauge the interest level of primary care physician providers outside of New York City and other large cities in terms of getting involved in bioevent preparedness?

Debra Berg: That's a very good question. And I look at it a slightly different way. I look at it as a dual purpose use. I mean the facts are this: Whether or not we have another bioterrorism event is unknown, but we do know that we have outbreaks; the occasional case of measles comes to the primary care center, where screening and isolation protocols have to be in place prior to the child getting to the exam room.

We also know that primary care centers need to be brought into the fold as it comes to receiving health alerts; what's the latest on the avian flu in Southeast Asia? What are the travel advisories that are circulating?

And lastly, the communication systems, in case there was an emergency, it's very important that primary care centers have a way to hook in, either by radio or E-mail or fax machine, to understand what's going on in their community, whether it be for a bioevent or for another type of emergency.

So we try to make these projects and the education materials to be very user friendly and to be used right from the start rather than having to wait for an emergency.

Cindy DiBiasi: We have a caller; Shawn McCarthy from Wisconsin is on the line. Hello?

Caller: Hello. Shawn McCarthy, Maraschino Clinic Employee Health and Safety Nurse for the West Division. Quick question for the panel. Have you looked into using clinics throughout areas as a support, because in most disasters, when people are looking for care they're going to not want to wait in line for health care facilities or some of these other facilities, they'll go to their primary care provider? Has the panel looked into the use of some of the large clinic systems that are in the area for this?

Cindy DiBiasi: Who would like to start with that question?

Debra Berg: I'd be glad to start. That plan works very well when the clinic is affiliated with a hospital. And in fact, in New York City, as I suspect in other jurisdictions, there already is planning going on between hospitals and their affiliated primaries care centers.

I think it becomes more complicated, and we're beginning to work on this, and that is when the hospital is surrounded by primary care centers, but they may be freestanding primary care centers or they may be affiliated with another hospital, and what we're working on is the integration of the hospital with nonaffiliated primary care centers so that they can serve the purpose of surge capacity enhancement and other roles during an emergency.

And it's been challenging, but I think we're one step closer to doing that, because primary care centers have achieved a certain level of preparedness, so now they speak the same language of the hospitals and are incorporated into a lot of our planning activities that are occurring in the city.

Cindy DiBiasi: Lucy, would you like to add to that?

Lucy Savitz: I would just like to add, AHRQ sponsored a series of site visits around the country. Actually, the User Liaison Program. And one of the promising practices that we observed was observed in Salt Lake City, Utah. In their planning for the winter Olympics that occurred there, there was a whole network of coordinated activity between clinics and hospital facilities. So I would point you in that direction in looking for more information.

Cindy DiBiasi: Andrea?

Andrea Hassol: We didn't look at the issue of clinics in our study.

Cindy DiBiasi: Okay. We do have an E-mail question for Lucy Savitz. Are the RTI Atlas of Nursing Home Surge Capacity Maps available for all States, and how can they be accessed?

Lucy Savitz: Sure. Thank you. There will be two levels of maps in the atlas. There will be the general map for all 50 States and then the drill-down maps with the actual geographic boundary comparisons and the Red Cross region overlays for the six case study States. The atlas will be available in July of this year.

Cindy DiBiasi: And I want to give Richard Zane the opportunity to answer, and join in anytime you want to, Richard, by phone.

Richard Zane: Well, thank you very much. I just wanted to add one comment to the question about using primary care sites. We didn't look at it in our study, but in Boston, for our health care system, what we have done is integrated the primary care sites as part of another asset that the acute care hospital has so that we can look at a broad picture of every asset that the hospital has. And that would be included, and it is a place where we would direct acute types of patients that were appropriate for a primary care setting.

Debra Berg: That's a very good point. In fact, we relied a lot on the Boston plan for the New York City plan, and we really liked the idea of hospitals inventorying their ambulatory care centers by the type of staff, by title, the type of equipment, whether they had chest x-ray equipment, the casting equipment, surgical supplies, et cetera.

And that's been a very helpful tool. We worked with Rick Serrano, who has been just fabulous in this whole area of ambulatory care preparedness and integrating them into the hospital arena in Boston.

Cindy DiBiasi: Lucy, let me just ask you what types of products are being prepared as a result of your research.

Lucy Savitz: Well, we'll have a case study series for the six States that we're looking at in detail, where we're doing these focus groups and looking at disaster plans in more detail. In addition, there is, as I mentioned earlier, a long-term care survey that was developed by Dr. David Doso when he was doing his fellowship at University of Pittsburgh Medical Center.

He's now at Brown University. And what we're doing basically with the focus groups is validating that instrument, and it can be used by States, by regions, to actually survey and inventory the capacity and special needs of the nursing homes in their area. And then thirdly, we have the atlas product that will come out.

Cindy DiBiasi: Okay. And Lucy, a question just for clarification. You were not talking about taking potentially infectious patients into a nursing home.

Lucy Savitz: No, we're not. We don't mean to suggest that in any way. These are vulnerable patients to begin with, and so you would not want to do that. But what you could potentially do is take stabilized elderly patients out of the hospitals and free beds for victims of an event.

Cindy DiBiasi: Okay. And the question for Andrea or for Richard, how would someone go about assessing a closed hospital to see if it might be suitable?

Andrea Hassol: Well, I can start off and then maybe Rich can jump in. This is exactly one of the questions we faced. How would you assess a closed hospital to see what was there and what could be used and more importantly what wasn't there? We did studies of two hospitals that are essentially closed and vacant in the Boston area, and we took multispecialty teams. We took people from hospital security.

We took people who are specialists in utilities, in materials management, in hospital food preparation areas, physicians looking at patient care spaces, nurses looking at nursing stations, all the different parts of the hospital.

And we took all the different kinds of people who would be concerned with figuring out what's there and what is not. Once we had a good picture of what's there, we developed a checklist that's going to be available to others.

This is one of the tools that's coming out of our project, that you can use as you walk through a shuttered hospital there are sections for each of the kinds of people I just mentioned to figure out what's there and what isn't.

Once you know what isn't there, then you have to go about finding all of those things and getting them prepared and ready so that, should there be an emergency, you can draw on them. And we also have a planning guide for suggestions for how to go about doing that. Rich?

Richard Zane: One of the most important things that we did is when we brought these specialists and their area of expertise to the hospitals is we gave them a time frame that could we do this in 3 to 5 days? We felt that the acute-care hospitals would be able to be sufficient for 3 days based on guidance from other places, and we said, "The question is, can you do this in 3 to 5 days?"

And the answer could be "No." And that was just an important an answer as "Yes, and here's how you do it," because knowing that you cannot do it at least takes that asset off of your armamentarium and allows you to move on to something else.

Cindy DiBiasi: And Rich, we have another question for and you Andrea that just came in, so I'm going to start with you on this one. What consideration should be given towards utilizing decommissioned military bases for mass casualty care such as those bases that were recently announced? And that comes from Rick Skinner, the Health Geographic's Program at Bay State Health System in Springfield, Massachusetts.

Richard Zane: Well, from the context of facility planning, a facility is a facility. So what assets are in place and what the plans are for that asset after it's been decommissioned. What we found is that no matter what the asset was, if it was a dead hospital, and what we mean by dead is no power, no plumbing, no nothing, then it was exceedingly unlikely that there was any chance that it could be open in 3 to 5 days.

What may be able to be discussed prospectively is what could we do or what one should do to look at those assets to maintain them in some minimum way so that they could be used for some type of mass casualty event? And the most important point is to ask the question, to look at the asset, do an inventory, and see what is necessary prospectively.

Cindy DiBiasi: Okay. A question for Lucy, from Mississippi. In Mississippi, recent regulations were passed that require a long-term care facility to have a disaster preparedness plan on file with the State EMA and health department, and additionally, this plan must be approved by the local EMA department. Will this project that's mentioned be a nationwide proposal, or one that is focused to a certain region of the Nation?

Lucy Savitz: Let me respond to the first question that was asked before I answer that question. The other thing that I would mention when we think about the decommissioned military hospitals or closed VA hospitals or other types of shuttered facilities is what they say in real estate: location, location, location.

So I think it's a real opportunity for researchers like Andrea and myself to come together and say, "How could we look at where these facilities are located relative to threats and other types of gaps in preparedness response?"

And then, from Mississippi, thank you for pointing this out. We'll be sure to look at what you're requiring in your State. Our study actually is an Integrated Delivery System Research Network Study (IDSRN), so we are working with our hospital system partners in six States. Our detailed case study analysis is only in those six States that I've already mentioned. So we're not doing it nationwide. We are focusing on those six States.

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