Preparing for Emergencies: Communication, Funding, and Innovation

With hospitals and health care systems already under constant pressure to be adequately prepared for natural disasters and other emergencies, refining risk assessments and a network of partners with clear communication actively in place has become even more critical.

In the last days of May 2020 following the murder of George Floyd in south Minneapolis, civil unrest descended into nights of rioting marked by arson,
violence, and when the smoke cleared, blocks of debris where many small businesses once thrived.

John Hick, MD, an emergency room physician at Hennepin Healthcare in downtown Minneapolis, was at work when 26 patients were admitted to the trauma service for burns and other injuries resulting from the violence. With a hospital already straining under the weight of COVID-19 patients, having to take responsibilities of an additional incident was taxing.

“We were fortunate that we had agreements with other hospitals to take patients from us to open up capacity,” said Dr Hick.As director of emergency preparedness at Hennepin Healthcare, Dr Hick also cited the good coordination the hospital system had with law enforcement and state and local agencies that facilitated the flow of vital information during a time of fear and uncertainty.

“We are fortunate in Minnesota to have a good relationship across the government to help,” he said. “That helped a ton.”

Hospitals and other health care entities are under constant pressure to adequately prepare for a range of disasters, from weather events to school shootings, terrorist attacks, cyberattacks, public health outbreaks, and much more. Preparation requires a litany of activities from completing an annual analysis of risk, training staff on preparedness and response, and running regular drills to ensure staff are ready.

The key to effective emergency preparedness planning is building a network of partners predicated on clear communication of needs and shared problem-solving and, importantly, a network that is in place prior to an event happening.

In 2002, following the events of September 11, federal funding became available to help subsidize critical components of emergency preparedness through the hospital preparedness program (HPP) grant administered via the US Department of Health and Human Services Assistant Secretary for Preparedness and Response (ASPR). Monies for this program flow from the federal government to the states that in turn disperse the funds through a competitive process to applying hospitals.

Funds are used to build health care coalitions that bring together emergency responders within a geographical area, such as acute care hospitals, emergency medical providers, public health agencies, and emergency management agents.

A common tool used in hospital preparedness is the Hazard Vulnerability Analysis (HVA), a tool that assesses the likelihood of an event occurring in a given geographical area and the impact it may have on the hospital system. The tool generates a relative risk ratio that offers people working on emergency preparedness plans an easy way to rank its top risks that inform their annual planning, explained David J Reisman, associate director of the Center for Disaster Medicine and vice president of Emergency Preparedness and Continuity for Mass General Brigham in Boston, MA.

When conducting an HVA, Mr Reisman emphasized the need to include stakeholders from across disciplines—physicians, nurses, administrators, security experts, facility experts, and others—for their input to ensure all potential areas of risk are considered.

The need to do an annual HVA is underscored by, for example, the changing weather patterns. He cited the example of tornados that years ago ranked low on their HVA as unlikely to occur in Massachusetts but now have a higher likelihood of occurring.

To adapt quickly to changing risks, as was needed to address COVID-19, Mr Reisman said that his institution employs an “all hazards approach” to preparedness. “An all hazards approach is designed to ensure flexibility and adaptability so we can respond to any type of event that occurs,” he said. “Importantly, it allows us to pivot and adjust as the situation changes.”

Mr Reisman said this approach has been critical during COVID-19 to continuously adjust to the changes in information and guidance on, for example, the availability and use of personal protective equipment.

Dr Hick commented that including senior level leaders in preparedness planning is also helpful and not something that may be done routinely. Prior to the pandemic, he said that a number of health care CEOs across Minnesota did not necessarily understand how much coordination was occurring between hospitals on emergency planning on a routine basis. “Getting them up to speed on the depths of planning was really helpful, he said.

In 2020, the American College of Healthcare Executives also issued a policy position stating “Health care executives should actively participate in disaster planning and preparedness activities” and provided a list of actions that health care executives should pursue in developing a comprehensive emergency operations plan (see Table).

For Beth Gatlin, RN, MA-HSM, ASPR project director, The Center for Health Affairs in Cleveland, OH, communication is the foundation on which all the elements of emergency preparedness are built. “You have to continuously hone communication before anything can be accomplished.” Ms Gatlin emphasized the importance of developing a network of partners and communication lines prior to an event. She added that COVID-19 forced the creation of new partnerships and enhanced others during the pandemic response (such as homeless shelters, prisons, and professional ball clubs) as well as new ways to communicate (like the expanded use of 211 for information to the public).

Although federal funding continues to flow through the HPP program and ASPR grants, the amount has drastically decreased since 2002. As an illustration, Ms Gatlin pointed to the significant cut in funding by 50% for the health care coalition she oversees in the northwest Ohio region, from $2 million in 2004 to the current $790,000.

From this amount, each hospital in the region receives on average $9000 to $12,000 annually (down from $40,000) to maintain their hospital emergency preparedness. Although she said the drop in funding has not fundamentally altered the readiness of the emergency preparedness programs in the region, she worries about the challenges to maintaining some readiness, such as updating and maintaining equipment. “Most hospitals don’t have budgets for emergency management and take the money out of a general fund or other workspace if needed,” said Ms Gatlin.

Since 2016, additional funding concerns have emerged given the new mandate by the Centers for Medicare & Medicaid Services that all Medicare and
Medicaid participating providers (such as skilled nursing and long-term care facilities) need to conduct emergency preparedness planning and coordinate with existing emergency planning systems.

Unlike hospitals, these providers are not eligible for funding via the HHP program. Health care coalitions, such as the one that Ms Gatlin oversees, must now include these facilities in their emergency planning.

Ms Gatlin questioned whether hospitals will pick up the slack to fund continued maintenance of equipment, or if nursing homes will pick up the cost of purchasing equipment if they can afford to fund it, or if not, let an item expire.

Saying that funding is never adequate for emergency preparedness, Dr Hick said funding did increase after COVID-19 but no one knows for how long or to what degree.

He cautioned, however, about extending the lessons learned from COVID-19 to future emergency preparedness given the differences in the types of risks posed by other types of events, such as mass shootings.

“We fundamentally need to rethink what we expect from our hospitals during a disaster response,” he said, citing, for example, the need to address equity issues. “If we really want to improve access for at-risk populations during a disaster, we’re going to have to put some public funding weight behind that.”

Given the ongoing need to improve emergency preparedness and response, ASPR has initiated an innovative approach based on the establishment of a Regional Disaster Health Response System (RDHRS).

Such a system is designed to support a more comprehensive and capable health care disaster response via a network of partners within states and across regions. Specific goals are to improve organization and coordination among all stakeholders (local, state, regional, and federal health care responders), improve situational awareness of medical needs and issues in response, increase health care coalition participation, and identify and further develop highly specialized clinical capabilities.

Four sites are currently testing demonstration to trial the effectiveness and viability of an RDHRS: Massachusetts General Hospital and Nebraska Medicine (since 2018), Colorado/Mountain Plans Regional Disaster Health Response System (since 2020), and Emory University (since October 2021).

Mr Reisman, who served initially as executive director of the Massachusetts RDHRS and currently as senior advisor, calls the RDHRS approach to emergency preparedness and response a “powerful tool.” He said that the approach has enhanced the existing response systems by providing expertise in clinical subject matter and health care operations to partners within the region.

During COVID-19, for example, he said the RDHRS helped with the clear flow of information among partners based on a common set of data point definitions.

“The RDHRS was an effective vehicle to widely share training resources, clinical protocols, and subject matter expertise with numerous health care systems across the region,” he said, adding that COVID-19 highlighted the value of rapid and structured access for partners within health care to experts with clinical and health care knowledge via the RDHRS. For more information on the program, visit phe.gov/preparedness.