[House Hearing, 111 Congress]
[From the U.S. Government Printing Office]
IS THE MEDICAL COMMUNITY READY IF DISASTER OR TERRORISM STRIKES:
CLOSING THE GAP IN MEDICAL SURGE CAPACITY
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FIELD HEARING
before the
SUBCOMMITTEE ON MANAGEMENT,
INVESTIGATIONS, AND OVERSIGHT
of the
COMMITTEE ON HOMELAND SECURITY
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
JANUARY 25, 2010
__________
Serial No. 111-50
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Printed for the use of the Committee on Homeland Security
[GRAPHIC] [TIFF OMITTED]
Available via the World Wide Web: http://www.gpo.gov/fdsys/
__________
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COMMITTEE ON HOMELAND SECURITY
Bennie G. Thompson, Mississippi, Chairman
Loretta Sanchez, California Peter T. King, New York
Jane Harman, California Lamar Smith, Texas
Peter A. DeFazio, Oregon Mark E. Souder, Indiana
Eleanor Holmes Norton, District of Daniel E. Lungren, California
Columbia Mike Rogers, Alabama
Zoe Lofgren, California Michael T. McCaul, Texas
Sheila Jackson Lee, Texas Charles W. Dent, Pennsylvania
Henry Cuellar, Texas Gus M. Bilirakis, Florida
Christopher P. Carney, Pennsylvania Paul C. Broun, Georgia
Yvette D. Clarke, New York Candice S. Miller, Michigan
Laura Richardson, California Pete Olson, Texas
Ann Kirkpatrick, Arizona Anh ``Joseph'' Cao, Louisiana
Ben Ray Lujan, New Mexico Steve Austria, Ohio
William L. Owens, New York
Bill Pascrell, Jr., New Jersey
Emmanuel Cleaver, Missouri
Al Green, Texas
James A. Himes, U.S. Virgin Islands
Mary Jo Kilroy, Ohio
Eric J.J. Massa, New York
Dana Titus, Nevada
I. Lanier Avant, Staff Director
Rosaline Cohen, Chief Counsel
Michael Twinchek, Chief Clerk
Robert O'Connor, Minority Staff Director
______
SUBCOMMITTEE ON MANAGEMENT, INVESTIGATIONS, AND OVERSIGHT
Christopher P. Carney, Pennsylvania, Chairman
Peter A. DeFazio, Oregon Gus M. Bilirakis, Florida
Bill Pascrell, Jr., New Jersey Anh ``Joseph'' Cao, Louisiana
Al Green, Texas Daniel E. Lungren, California
Mary Jo Kilroy, Ohio Peter T. King, New York (Ex
Bennie G. Thompson, Mississippi (Ex Officio)
Officio)
Tamla T. Scott, Director & Counsel
Nikki Hadder, Clerk
Michael Russell, Senior Counsel
Kerry Kinirons, Minority Subcommittee Lead
(II)
C O N T E N T S
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Page
Statements
The Honorable Christopher P. Carney, a Representative in Congress
From the State of Pennsylvania, and Chairman, Subcommittee on
Management, Investigations, and Oversight...................... 1
The Honorable Gus M. Bilirakis, a Representative in Congress From
the State of Florida, and Ranking Member, Subcommittee on
Management, Investigations, and Oversight...................... 2
Panel I
Dr. B. Tilman Jolly, Associate Chief Medical Officer for Medical
Readiness, Department of Homeland Security:
Oral Statement................................................. 5
Prepared Statement............................................. 6
Dr. Gregg A. Pane, Director, National Health Care Preparedness
Programs, Office of Preparedness and Emergency Operations,
Office of the Assistant Secretary for Preparedness and
Response, Department of Health and Human Services:
Oral Statement................................................. 8
Prepared Statement............................................. 10
Ms. Shannon Fitzgerald, Director, Pennsylvania Office of Public
Health Preparedness, Pennsylvania Department of Health:
Oral Statement................................................. 15
Prepared Statement............................................. 17
Ms. Cynthia A. Bascetta, Director, Health Care, Government
Accountability Office:
Oral Statement................................................. 20
Prepared Statement............................................. 22
Panel II
Dr. John J. Skiendzielewski, Director, Emergency Medicine
Services, Geisinger Medical Center, Danville, Pennsylvania:
Oral Statement................................................. 46
Prepared Statement............................................. 47
Mr. Michael N. O'Keefe, President and Chief Executive Officer,
Evangelical Community Hospital, Lewisburg, Pennsylvania:
Oral Statement................................................. 50
Prepared Statement............................................. 52
Mr. Robert A. Kane, Jr., Vice President of Operations,
Susquehanna Health, Williamsport, Pennsylvania:
Oral Statement................................................. 54
Prepared Statement............................................. 56
Mr. Gary A. Carnes, President and Chief Executive Officer, All
Children's Health System, St. Petersburg, Florida:
Oral Statement................................................. 58
Prepared Statement............................................. 59
For the Record
The Honorable Christopher P. Carney, a Representative in Congress
From the State of Pennsylvania, and Chairman, Subcommittee on
Management, Investigations, and Oversight:
Statement of The Hospital & Healthsystem Association of
Pennsylvania................................................. 44
IS THE MEDICAL COMMUNITY READY IF DISASTER OR TERRORISM STRIKES:
CLOSING THE GAP IN MEDICAL SURGE CAPACITY
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Monday, January 25, 2010
U.S. House of Representatives,
Committee on Homeland Security,
Subcommittee on Management, Investigations, and Oversight,
Danville, PA.
The subcommittee met, pursuant to call, at 11:05 a.m., at
Danville Borough Council Hall, Danville, Pennsylvania, Hon.
Christopher P. Carney [Chairman of the subcommittee] presiding.
Present: Representatives Carney, Bilirakis.
Mr. Carney. The Subcommittee on Management, Investigations,
and Oversight will come to order. The subcommittee is meeting
today to receive testimony on ``Is the Medical Community Ready
if Disaster or Terrorism Strikes: Closing the Gap in Medical
Surge Capacity.'' First, I would like to thank everyone for
joining us today. I would especially like to thank our Ranking
Member, Mr. Bilirakis, from Florida. Gus, this is as warm as we
could make it in Pennsylvania in January. I am also honored
that so many Federal and State experts were able to join us,
and I am extremely proud that so many of our outstanding local
hospitals are able to participate in today's hearing.
Today, we will examine how the Department of Homeland
Security coordinates the Department of Health and Human
Services, local hospital facilities, and public health
officials in establishing and coordinating a National medical
response strategy during an act of terrorism or public health
threat, including biological, chemical, or a radiological
event. It is my hope that this hearing will yield a clear
vision of how hospital systems located in rural communities
throughout the country receive vital information from Federal
and State government partners leading up to and during natural
or man-made disasters, and whether the plan that is currently
in place meets their needs.
The need to surge medically is widely recognized as being
necessary and the goals for increasing medical surge capacity
have long been established, but the ability for any hospital or
other health care delivery establishment in the United States
to do so is difficult. This is because health care delivery
programs are required to create the greatest amount of
efficiency with the least amount of waste while medical
preparedness activities demand that resources be stored in
advance of an event, thereby decreasing efficiency and
intentionally leaving resources unused.
Hospitals often wind up sacrificing the future for the
present especially given the current state of the economy.
Further, when grant programs provide little funding to cover
preparedness activities, preparedness quite literally does not
pay in the health care delivery system. We must, however,
ensure that every effort is made to prevent as much illness and
save as many lives as possible when large scale disasters and
acts of terrorism occur. We need only to look at the situation
in Haiti to see how important medical surge capacity and
preparedness is. It is imperative that we identify areas that
are still in need of additional resources and more focused
Congressional oversight is required.
In addition to the Commonwealth of Pennsylvania, efforts in
other States and territories should be characterized and
compared in order to better understand how to increase medical
surge capacity without negatively affecting profit margins.
Different sectors must partner with each other. When trusted
relationships are established information and resources are
shared to a much greater extent. Efforts need to be both
coordinated and integrated. Public health and health care
resources are limited so the efforts of these sectors need to
be as efficient as possible.
Finally, standard of care decisions need to be made now on
what to do when the number of patients needing treatment far
exceeds the number of resources available to treat them. I
would like to thank all the witnesses for their participation.
I look forward to their testimony. I would also like to thank
the Hospital and Healthsystem Association of Pennsylvania,
which was kind enough to submit written testimony for the
record. The Chair now recognizes the Ranking Member of the
subcommittee, the gentleman from Florida, Mr. Bilirakis, for
his opening statement.
Mr. Bilirakis. Thanks, Chris. I am happy to be here in the
district to consider the issue of medical surge capacity, and I
will tell you even though I am from Florida, my dad is from
Western Pennsylvania, a town called Clairton, and I love this
State. You always have a friend in Pennsylvania. Of course, I
root for the Pirates and the Steelers. Whether we are talking
about urban, suburban, or rural areas, this is a vital topic,
and I am pleased that the subcommittee is considering the issue
today. I welcome all of our distinguished witnesses here today,
including Gary Carnes from my home State of Florida.
I am interested in hearing about the challenges facing
Federal, State, and local governments, and the medical
community in addressing medical surge capacity and capabilities
during a natural disaster, terrorist attack, or other mass
casualty event, and in discussing those challenges, I hope our
witnesses will provide us with recommendations for what more
Congress can do to assist in these efforts. I would also like
to hear about the lessons we learned as a result of the H1N1
outbreak last year. Many experts say we dodged the bullet with
this pandemic and that it could have been far worse and
exceeded our medical capacity to respond successfully.
How did this test current capabilities and what changes
will you make to adapt to issues that arose? In light of H1N1's
impact on children, I am particularly interested in learning
about the challenges faced by the medical community in caring
for children and other special needs populations during this
pandemic and in other medical emergencies. Influenza is not the
only medical crisis that could push the hospitals and other
medical facilities to the edge of their capacity. A
radiological or nuclear bomb, a chemical explosion, or a
biological attack could cause emergency rooms to be flooded
with patients in ways in which hospitals are ill-prepared to
respond.
What would your hospital do with radioactive patients, with
patients that might be contaminated with anthrax spores? I look
forward to hearing from our local witnesses on their ability to
surge to meet the special needs of a bio-hazard event. Medical
surge is a problem faced by our local communities and health
care professionals, but because the ability to care for mass
casualties is a homeland and health security matter local
efforts must be supported by the Federal Government. That is
why I have introduced H.R. 4492, which reauthorizes the
Metropolitan Medical Response System Program and allows funding
to be used to strengthen medical surge capacity, develop plans,
and conduct training and exercises among other vital
activities.
In addition, H.R. 4492 authorizes funding to ensure this
program reaches its full potential. I look forward to working
with our witnesses on additional ways to support medical
preparedness and surge capacity efforts. Thank you, Mr.
Chairman. I yield back the balance of my time.
Mr. Carney. Today's hearing will be divided into two
panels. The first panel is comprised of Government witnesses,
and the second will be comprised of representatives from
hospital facilities. I welcome each of our witnesses to the
hearing and to Pennsylvania. Our first witness is Dr. B. Tilman
Jolly. Dr. Jolly is the Associate Chief Medical Officer for
Medical Readiness in the Department of Homeland Security's
Office of Health Affairs. Dr. Jolly began his service with DHS
in November 2006. The Office of Health Affairs oversees efforts
to coordinate medical first responders, ensures interagency
alignment of health and medical preparedness grants, develop
policies and programs to enhance all hazardous planning,
promote integration of State and local response capabilities,
and prepare for and respond to catastrophic events.
Dr. Jolly has practiced emergency medicine in the
Washington, DC area for 17 years. He remains Associate Clinic
Professor of Emergency Medicine at the George Washington
Hospital. In 1992, he completed training at the Georgetown-
George Washington combined residency in emergency medicine and
is a Board-certified emergency physician. He has been a staff
physician at numerous hospitals and continues to practice at
Enola Fairfax Hospital, a regional trauma center, for northern
Virginia. A native of North Carolina, Dr. Jolly received his
undergraduate degree from the University of North Carolina as a
Morehead Scholar and has a medical degree from Bowman Gray
College School of Medicine at Wake Forest University. He
resides in northern Virginia with his wife and four children.
Our second witness is Dr. Gregg A. Pane. Dr. Pane is
currently the Director of National Health Care Preparedness
Programs for the U.S. Department of Health and Human Services.
The program provides $500 million on grant funding to States
and partnerships to improve National hospital and health system
preparedness. From 2004 to 2007, Dr. Pane was the director of
the District of Columbia Health Department or DOH. In that
position, he headed a $2 billion 1,300 staff agency responsible
for Medicaid public health programs, health facility and
professional board licensing and certification, State health
planning, and epidemiology, environmental health, and public
health preparedness.
While at DOH, Dr. Pane led the emergency response for
anthrax, mercury spills, pandemic flu, the flu vaccine crisis,
Katrina evacuees, and the 2005 Presidential inauguration. Dr.
Pane was born in Flint, Michigan, and received his
undergraduate degree of the University of Michigan at Flint.
Dr. Pane holds a medical degree from the University of Michigan
and a Master's degree in public health services administration
from the University of San Francisco. He has made numerous
appearances on local and National media, including CNN, NPR,
Fox, CBS, BBC, ABC, and Japanese TV.
Our third witness is Ms. Shannon Fitzgerald. She is the
Director of the Office of Public Health Preparedness which
supports the Pennsylvania Department of Health's efforts to
prepare for and protect against, respond to, and recover from
all acts of bioterrorism and other public health emergencies.
As OPHP director, Ms. Fitzgerald's responsibilities include
developing and administering Pennsylvania's public health
preparedness, operations, and bio-terrorism response capability
and formulating policy and providing policy direction at the
local, regional, and State-wide level.
Prior to coming to the Pennsylvania Department of Health,
Ms. Fitzgerald served as the Public Health Preparedness program
manager for the Philadelphia Department of Public Health. Ms.
Fitzgerald also was previously employed as the emergency
preparedness planner for the southeastern Pennsylvania chapter
of the American Red Cross. Ms. Fitzgerald received a Master's
of city planning and a Master's of government administration
from the University of Pennsylvania in Philadelphia, and a
Bachelor's of Sociology from the University of Dayton in
Dayton, Ohio.
Our fourth witness is Ms. Cynthia Bascetta. Ms. Bascetta
serves as Director of Health Care Issues for the Government
Accountability office or GAO. She is responsible for leading
reviews of programs designed to protect and enhance public
health. Ms. Bascetta is currently leading GAO's public health
work with a focus on quality of care and disaster preparedness
and response. She directs work on diverse issues such as
prevention of health care association, associated infections,
delivery of mental health services, and access to community
health centers.
She has also led reviews of the Federal response to
Hurricane Katrina and the attack on the World Trade Center.
Before that, she directed GAO's reviews of the effectiveness
and the efficiency of VA's health care system and disability
compensation programs at the Department of Veterans Affairs and
the Department of Defense. She joined the GAO in 1983 after
conducting regulatory impact analysis of major occupational
health rules at the U.S. Department of Labor. She has a
Bachelor's degree in Government from Smith College and a
Master's in applied economics from the University of Michigan,
and a Master's in Public Health from the University of
Michigan. The University of Michigan is highly represented here
today.
Without objection, the witnesses' full statements will be
inserted in the record. I now ask each witness to summarize
your statement for 5 minutes beginning with Dr. Jolly.
STATEMENT OF B. TILMAN JOLLY, M.D., ASSOCIATE CHIEF MEDICAL
OFFICER FOR MEDICAL READINESS, DEPARTMENT OF HOMELAND SECURITY
Dr. Jolly. Thank you, Chairman Carney, Ranking Member
Bilirakis. I want to thank you for the opportunity to
participate in this field hearing to discuss the important
issues of medical readiness and medical surge. I will just
summarize my statement over a few minutes because I know we
have a lot of important questions to get to. On behalf of
Secretary Napolitano, who is very interested in these issues
also personally, I would like to take the opportunity to thank
you and the subcommittee for your continued work alongside DHS
to provider leadership in protecting and ensuring the safety
and preparedness of the homeland. I would also like to thank
our Federal, State, local, and other partners, and particularly
the partners from DHHS, with whom we work every day on a
continual basis. This is just sort of an extension of that up
here in a different city, but this is a group that we work with
daily on all these issues.
Today I am going to address just some basics of medical
readiness and medical surge and talk a bit about the Office of
Health Affairs in the Department of Homeland Security and the
other departments of the Department of Homeland Security that
work on these issues. Medical surge is an element of our
overall preparedness but one of many critical elements, and as
anyone who has worked around hospitals and around health care
facilities knows the interconnectedness of those facilities
into broader community critical infrastructures is key,
especially when a crisis happens. All of the infrastructures
need to work together, emergency preparedness, transportation,
water, and others to make the system work.
Now what I will talk about are some of the specific local
response issues. In fact, Dr. Pane and I both had long
experience in health care systems and a system like Geisinger
who was very gracious to us this morning to show us their new
facility really operates on a surge model every day because
things happen for specific hospitals and communities every day
from a bus rolling over to a fire to a critical response, and
hospitals are quite good at managing their resources locally
and even reaching out through mutual aid agreements to their
county and regional partners to effect a response, and this
something they work on and practice and can teach us a lot
about.
But when a large-scale either natural disaster or terrorist
event happens, those that you talked about, radiation-related,
nuclear-related, biological, chemical, or others, it really
requires a regional, National, and sometimes, as we see
tragically today, international response to manage and to get
the flow of goods, health care to the affected people and
sometimes to get those people out of where they are into
definitive care. In these situations, DHS is the overall
response manager under the National Response Framework that has
been tried and tested in many situations, and also under the
framework of the Department of Health and Human Services to
lead for what we call ESF-8, Emergency Support Function--8,
which is public health and medical which is clearly a key among
the 15 emergency support functions.
DHS through the Secretary and through the FEMA
administrator lead the overall management of that and work very
closely with Secretary Sebelius and her staff to effect these
responses. Now our office, the Office of Health Affairs, which
is relatively new in the Federal Government, serves as the
principal health and medical advisor to both the Administrator
of FEMA and to Secretary Napolitano. On a very practical level
that occurs almost daily for things like H1N1, for other
threats, for emergency response to natural disasters and other
like incidents.
Through our Office of Medical Readiness, which resides
within my purview, we work with other DHS components and with
our Federal partners and with State and local partners to work
on some of the integration issues which you have highlighted.
We also on an operational basis moved to staff the National
Response Coordination Center, the National Operations Center,
the Secretary's Operation Center at HHS to improve that
coordination flow when there is an operation required and move
through that to effect communications. You talked a bit, Mr.
Bilirakis, about trusted relationships, and Mr. Carney both,
about how those trusted relationships are formed. We are also
working in a specific way with some of the fusion centers
around the country to try to in effect improve collaboration
between public health and the largely law enforcement elements
that brought up those fusion centers, and that is a work in
progress but I think something that is a goal that the prior
Secretary and the current Secretary both endorse and want to
move forward on.
Now there is, of course, a pandemic going on and we talk a
lot about what we have learned from H1N1. Although after-action
is really not the right term to apply to something that is
still going on but the process of gathering data and
information about how that response happened, what our
assumptions were at the beginning of that incident and even
before that incident, and how we have learned how to do that
communication. We are working very closely with Dr. Pane's
office to gather information now. I think we have learned a lot
about how to educate the public, how to educate providers, and
how to educate communities about how to handle unusual long-
lasting biological events, and we look forward to working with
you on that. I will close now and just thank you for your time
and look forward to working with you and yield to Dr. Pane.
[The statement of Dr. Jolly follows:]
Prepared Statement of B. Tilman Jolly
introduction
Good morning Chairman Carney, Ranking Member Bilirakis, and Members
of the subcommittee. Thank you for the opportunity to participate in
this field hearing to discuss medical readiness and medical surge
issues. On behalf of Secretary Napolitano, I would like to take this
opportunity to thank you and the subcommittee for your continued work
alongside the Department of Homeland Security (DHS) to provide
leadership in protecting and ensuring the security of our homeland. I
would also like to thank our Federal, State, local, Tribal,
territorial, and private sector partners, including the Department of
Health and Human Services (HHS) and others with whom we work every day.
Today I will address medical readiness and medical surge within the
scope of overall emergency preparedness and response capabilities. In
particular, I will discuss the roles and responsibilities of the DHS
Office of Health Affairs (OHA), and highlight key areas of coordination
between DHS and HHS.
HHS is the lead Federal agency for public health and medical
preparedness and response issues and consequently coordinates and
provides the health care and medical response in a major disaster or
other catastrophic incident. DHS supports HHS in this mission.
coordination with the department of health and human services
The authorities for mass casualty events are enumerated in several
places, including the National Response Framework (NRF) Emergency
Support Function--8: Public Health and Medical Services, as well as in
statutory authorities. Per the NRF, HHS is the lead Federal agency in
preparing, deploying, and providing health and medical care to the
public in the event of a disaster or other emergency.
OHA and FEMA both work closely with the HHS Office of the Assistant
Secretary for Preparedness and Response and the Centers for Disease
Control and Prevention on a daily basis to bolster our ability to
effectively prepare for and respond to a major emergency.
department of homeland security responsibilities
The Department of Homeland Security's mission is to secure the
country against the many threats we face; should a catastrophic
incident occur, DHS leads overall incident management activities.
Medical surge capacity is a critical element of local, State, and
National resiliency. Local medical providers deal with localized surge
needs on a regular basis. Mutual aid agreements, communications
protocols, and coordinated plans, all utilized by skilled professionals
enable communities to deal with localized emergencies. The Federal
Government will continue to support local capabilities as we assist in
the coordination of broader regional capabilities.
The focus of our planning at the Federal level is on crises that
overwhelm local and State resources. When a large-scale natural
disaster or terrorist incident occurs, the ability to provide urgent
and life-saving medical care, through coordinated resources from the
local, State, and Federal levels, directly affects the ability to save
lives.
Whether the event is the detonation of an improvised nuclear device
or an influenza pandemic, the capacity to handle a large number of
casualties will be the fundamental standard by which we measure success
in our overall response.
In a large multi-casualty event, many emergency departments and
hospitals would be overwhelmed with individuals suffering from
illnesses and injuries ranging from relatively minor to life-
threatening. In this situation, HHS would serve as the lead agency for
coordinating health response activities. DHS would be responsible for
support to facilitate effective medical response within the context of
all the other demands of the event, including law enforcement,
environmental, intelligence-gathering, public safety, communications,
and search and rescue.
office of health affairs medical readiness and medical surge activities
Within DHS, OHA serves as the primary advisor to the Secretary and
the Administrator of the Federal Emergency Management Agency (FEMA) on
medical and public health issues. OHA leads workforce health protection
and medical oversight activities, leads and coordinates the
Department's biological and chemical defense activities, and provides
medical and scientific expertise to support DHS' preparedness and
response efforts.
OHA, through its Office of Medical Readiness and in collaboration
with other DHS components and Federal departments and agencies, is
working on a number of initiatives to improve our Nation's medical
readiness. OHA plays an important supportive role in medical and health
disaster planning, overseeing the health aspects of contingency
planning for all chemical, biological, radiological, and nuclear
hazards. OHA supports incident response operations by providing
expertise and advice to the Secretary and FEMA Administrator and staff
to the DHS National Operations Center and HHS Secretary's Operations
Center, and assisting FEMA in evaluating State and local medical
resource needs and requests during a disaster. OHA also provides
medical subject matter expertise to FEMA's Homeland Security Grant
Program, including the Metropolitan Medical Response System. OHA works
to ensure that grant recipients across the country build medical
response and medical surge capabilities by providing guidance and
information to grant recipients and medical first responders. OHA is
also facilitating medical and public health communities' participation
in fusion centers. This coordination is beneficial because the health
community can translate and share valuable health information, trends,
and issues to inform actionable intelligence.
state and local response
State and local responders play an essential role in the immediate
aftermath of a catastrophic event. When a disaster strikes, it is the
local first responders who arrive on the scene to provide initial
assessment of the extent of the incident, the numbers of casualties,
property damage, and resources needed to transport victims. Medical
issues are addressed by local EMS, health care facilities, and public
health agencies.
Depending on the magnitude of the event, the response activities
(including personnel, equipment, and supplies) will expand from local
health resources to surrounding regions, State resources, adjoining
State resources, and Federal resources. DHS is committed to ensuring
that the Federal response, whether it is a medical, environmental, or
law enforcement response, is well-coordinated with State and local
officials to ensure a seamless and integrated response. The role of the
Federal Government is to supplement State and local efforts and to
provide assistance when it is needed.
OHA and FEMA work closely with HHS, States, and local authorities
to develop inter-State and multi-State agreements to provide supplies,
hospital beds, and medical professionals during a catastrophic event.
These partnerships are important to ensuring medical surge capacity.
conclusion
Mr. Chairman, thank you for having this hearing today. Medical
surge capacity is a significant part of any effective National
emergency preparedness and response capability. I would be happy to
answer any questions.
Mr. Carney. Thank you for your testimony. Dr. Pane for 5
minutes, please.
STATEMENT OF GREGG A. PANE, M.D., DIRECTOR, NATIONAL HEALTH
CARE PREPAREDNESS PROGRAMS, OFFICE OF PREPAREDNESS AND
EMERGENCY OPERATIONS, OFFICE OF THE ASSISTANT SECRETARY FOR
PREPAREDNESS AND RESPONSE, DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Dr. Pane. Yes. Thank you, Chairman Carney, Ranking Member
Bilirakis. It is a pleasure to be here with my colleague, Til
Jolly, and others. Dr. Lurry and Dr. Yeski send their regards.
We are in the middle of the Haiti response and getting ready
for the State of the Union this week, a lot going on. I did
want to before I start summarizing my testimony thank you for
arranging the tour of Geisinger Medical Center today. I think
it was extraordinarily impressive state-of-the-art facility. It
is wonderful seeing innovative going on locally, which is what
we are hoping to achieve.
Again, I am Gregg Pane. I am Director of the National
Health Care Preparedness Program of HHS, which is the Hospital
Preparedness Program and the Health Volunteer Program called
ESAR-VHP. Again, it is a pleasure to be here. Briefly, as Dr.
Jolly alluded to, our HHS Secretary, she is the lead Federal
official for public health and medical response. We work very
closely with DHS under the National Response Plan and support
them in their lead role. This is all, of course, under the
National Response Framework with HHS. ASPR, Assistant Secretary
for Preparedness and Response is the entity which coordinates
Federal public health and medical assistance to State, local,
territorial, and Tribal jurisdictions during an emergency.
Under the framework, HHS and DHS work very closely
together, as Dr. Jolly alluded to. We have regular contact and
meetings with the Office of Health Affairs, and certainly in
times of response DHS and HHS work closely in each other's
command centers and speak really daily and we work in each
other's operations centers locally at the site of an incident
as well. Of course, we work closely with FEMA and their
officials. HHS has awarded over $300 million in funding to the
State of Pennsylvania and over $477 million to the State of
Florida through our combined HHS grant programs. One is the CDC
Public Health Emergency Preparedness Program, known as the PHEP
program, and the other is ASPR Hospital Preparedness Program
known as HPP.
I think PHEP has greatly increased the preparedness
capabilities for public health departments across the country
and includes targeted funding to support medical surge and the
public health workforce. The Hospital Preparedness Program,
HPP, is dedicated to enhancing medical surge capacity through
cooperative agreements to States based on population. Funding
is dedicated primarily for hospital emergency facilities, their
communications needs, exercises, fatality management, and a
host of other priorities.
I did want to highlight while I was here the Healthcare
Facilities Partnership of South Central Pennsylvania, which was
one of the HPP demonstration pilots we were able to launch a
couple of years ago. It was designed to improve surge capacity
in the south central Pennsylvania region. It has provided
simulation training to over 1,000 personnel within the 17
institutions in the areas of pan flu, blast/mass casualty and
hospital evacuation. I think it has helped promote mutual
collaboration and problem solving through Hershey Medical
Center and the acute care hospitals in the region to exercise
as another contact.
HHS has developed a mechanism to maintain situational
awareness for hospital status called the HAvBED system, which
is the Hospital Available Beds in Emergencies and Disasters.
HAvBEDs are our primary way of understanding what beds are
available to States and HHS operations centers, and States and
hospitals respond within 4 hours of a request for the bed
status. In 2005 the Florida Agency for Health Care
Administration established the Emergency Status System, which
is fully integrated with HAvBED requirements. This is a web-
based system designed to track impact of emergencies on
providers, including hospitals, into an effective response to
disasters.
As I alluded to, a second part of the Hospital Preparedness
Program is the ESAR-VHP program, Emergency System for Advanced
Registration of Volunteer Health Professionals, a very
important part. This is a National program intended to help
health professionals volunteer in public health emergencies and
disasters and to ensure the availability of volunteers for
quick exchange between jurisdictions. HHS works very closely
with States and communicates with them through various means.
Our regional emergency coordinators are in regular contact with
their counterparts. HPP leadership have regular calls and
contact through meetings and calls with our State leaders in
Hospital Preparedness.
In addition, ASPR has a frequency of communications with
FEMA, DHS, and we work closely with States during calls through
their EOC and other mechanisms. Again, I will stop there and
just say that our work to enhance medical surge continues to
move forward. We thank you very much for your support and
leadership in these areas. The responsibility for medical surge
capacity is certainly one that is shared at the local, State,
and Federal levels and includes private, as well as public
partners, and it certainly starts with the individuals at home.
So again with your leadership and support, we have made
substantial progress. We thank you, and I am happy to take any
questions.
[The statement of Dr. Pane follows:]
Prepared Statement of Gregg A. Pane
January 25, 2010
Good morning Chairman Carney and distinguished Members of the
subcommittee. I am Dr. Gregg A. Pane, the Director of National Health
Care Preparedness Programs in the Office of Preparedness and Emergency
Operations, within the Office of the Assistant Secretary for
Preparedness and Response (ASPR), U.S. Department of Health and Human
Services (HHS). It is a privilege to present to you the progress HHS
has made in our Nation's public health preparedness, specifically our
work with Federal, State, and local partners to enhance surge capacity
within the medical community. I want to also commend this subcommittee
for its leadership in holding today's hearing and share your sense of
urgency on this important issue.
pandemic and all-hazards preparedness act
The Pandemic and All-Hazards Preparedness Act (the act) designates
the HHS Secretary as the lead Federal official for public health and
medical response to public health emergencies and incidents covered by
the National Response Plan developed pursuant to section 502(6) of the
Homeland Security Act of 2002, or any successor plan, and creates the
Assistant Secretary for Preparedness and Response. Under the act, ASPR
plays a pivotal role in coordinating emergency public health and
medical response efforts across the various HHS agencies and among our
Federal interagency partners.
Public health preparedness involves a shared responsibility among
our entire Department, our partners in the international community, the
Federal interagency, State, local, Tribal, and territorial governments,
the private sector, and, ultimately, individuals and families. In
addition, we believe that medical surge capacity is part of an all-
hazards approach to preparedness. The gains we make in increased
preparedness and response capability help us across the spectrum of
public health emergencies and disasters.
coordination with the department of homeland security
HHS supports DHS in its role as the lead for the integrated Federal
response under the National Response Framework (NRF). Within the NRF,
HHS is responsible for coordinating the Emergency Support Function
(ESF) No. 8--Public Health and Medical Services and ASPR has been
designated by HHS as the office to coordinate the Federal public health
and medical assistance to State, local, territorial, and Tribal
jurisdictions during an emergency.
ASPR works closely with the Department of Homeland Security's
Office of Health Affairs (OHA) and the Federal Emergency Management
Agency (FEMA). At the Headquarters level, ASPR and OHA have weekly
telephone meetings to discuss issues and activities of mutual interest.
During times of response, DHS and FEMA participate in the ESF No. 8
teleconferences and they send liaison officers to the HHS Operations
Center. HHS also sends liaison officers to the FEMA National Response
Coordination Center and to the FEMA Regional Response Coordination
Center in the affected area. At the Regional level, HHS has regional
emergency coordinators who work closely with the FEMA Regional
Administrators to coordinate Federal preparedness and response
activities within the region. HHS and DHS continue to work on
coordinating our grant assistance to States. We have an established
working group which is coordinating the programmatic aspects of our
respective grants programs. Within each of these important coordination
mechanisms, Federal interagency partners also report their activities
for group discussion and integration.
regional emergency coordinators
HHS has worked diligently to partner with State, Tribal,
territorial, and local officials to enhance their level of preparedness
and to ensure they can see how HHS will respond to disasters. ASPR
Regional Emergency Coordinators work with State/Tribal/territorial
officials from the Departments of Health, Emergency Management, and
Homeland Security to coordinate and enhance preparedness within the
region. HHS Centers for Medicare & Medicaid Services (CMS) regional
representatives also take an active role at the local level for
hospital preparedness.
To better serve Hospital Preparedness Program (HPP) recipients,
ASPR began hiring regional coordinators for the HPP program last year
and is scheduled to have a coordinator in each of the 10 HHS regions by
the end of this fiscal year.
enhancing state and local preparedness
The Department has awarded over $350 million in funding to the
State of Pennsylvania through the ASPR Hospital Preparedness Program
(HPP) and the Centers for Disease Control and Prevention (CDC) Public
Health Emergency Preparedness Program (PHEP). Funding has been
allocated for the upgrading of State and local medical surge capacity,
including hospital emergency care, communication, exercises, and
fatality management. A summary of fiscal year 2009 funding provided to
Pennsylvania under these programs is below:
------------------------------------------------------------------------
Fiscal Year
Program 2009 Funding
------------------------------------------------------------------------
Hospital Preparedness Program........................... $14,103,046
ESAR-VHP in PA.......................................... 60,000
Public Health Emergency Preparedness Program............ 22,975,362
------------------------------------------------------------------------
hospital preparedness program
The Hospital Preparedness Program (HPP) is a program dedicated to
enhancing medical surge capacity (http://www.hhs.gov/aspr/opeo/hpp).
Funding allocations are made through formula cooperative agreements to
States based on population, and through competitive grants. HPP funding
comes from annual appropriations, as well as certain supplemental
appropriations, including $90 million from the Supplemental
Appropriations Act 2009 (Pub. L. 111-32) and the Emergency Supplemental
Appropriations Act to Address Hurricanes in the Gulf of Mexico and
Pandemic Influenza, 2006 (Pub. L. 109-148). Generally, HPP funding is
dedicated for hospital emergency facilities, communications, exercises,
and fatality management. Priorities for Medical Surge that were
evaluated as part of the State plan review are as follows:
States have the ability to report available beds which is a
requirement in the 2006 Hospital Preparedness Program
Cooperative Agreement;
Effective use of civilian volunteers as part of the
Emergency System for Advance Registration of Volunteer Health
Professionals (ESAR-VHP) and Medical Reserve Corps (MRC)
programs;
Planning for Alternate Care Sites;
Development of Health Care Coalitions that promote effective
sharing of resources in surge situations; and,
Plans for providing the highest possible standards of care
in situations of scarce resources. ASPR partnered with the HHS
Agency for Healthcare Research and Quality (AHRQ) in the
development of a Community Planning Guide on Mass Medical Care
with Scarce Resources.
hpp demonstration project
Beginning in September 2007, as part of the HPP program discussed
above, an HPP demonstration project called the Healthcare Facilities
Partnership of South Central Pennsylvania, was initiated in Hershey,
Pennsylvania. The Partnership was designed to improve surge capacity
and to enhance community and hospital preparedness for public health
emergencies in defined geographic areas within the South Central
Pennsylvania region and was successful in achieving the following
goals:
1. Enhanced situational awareness of capabilities and assets in the
South Central Region of Pennsylvania;
2. Develop and pilot test advanced planning and exercising of plans
in the Region;
3. Complete written Medical Mutual Aid Agreements between health
care facilities in the Region, with a special emphasis on
hospitals;
4. Develop and strengthen Partnership relationships through joint
planning, frequent communication, simulation, and evaluation of
preparedness;
5. Ensure National Incident Management System (NIMS) Compliance,
including for the 14 new NIMS activities, for all hospitals in
the Region;
6. Develop and test a plan for effective utilization of ESAR VHP
volunteers.
The Partnership provided exercise solutions through the development
and facilitation of three high fidelity simulations. To date it has
provided simulation training to over 1,000 personnel within the 17
institutions in the subject areas of: Pandemic Influenza Epidemic,
Blast/Mass Casualty, and Hospital Evacuation. It also promoted mutual
collaboration and problem solving with the acute care hospitals through
frequent exercises.
Recognizing the importance for continued training and evaluation in
the areas of preparedness, the Partnership will use a mobile training
and evaluation vehicle, called ``Lion Reach'' to provide a multitude of
training opportunities for the South Central Pennsylvania Region. The
Lion Reach training vehicle will support the partnerships on-going
efforts to sustain the gains already achieved.
esar-vhp
The Emergency System for Advance Registration of Volunteer Health
Professionals (ESAR-VHP) is a National program intended to help health
professionals volunteer in public health emergencies and disasters and
to ensure the availability of volunteers for quick exchange between
jurisdictions. The ESAR-VHP program is working to establish a National
network of systems, each maintained by a State or group of States, for
the purpose of verifying the credentials, certifications, licenses, and
hospital privileges of health care professionals.
ESAR-VHP in the State of Pennsylvania is known as the State
Emergency Registry of Volunteers in Pennsylvania, or SERVPA, which is
fully operational. Pennsylvania meets the ESAR-VHP compliance
requirements and works to continue adopting and implementing the
Interim ESAR-VHP Technical and Policy Guidelines, Standards, and
Definitions.
public health emergency preparedness program
From fiscal year 2002-fiscal year 2009, the Public Health Emergency
Preparedness (PHEP) program has provided $245 million to the State of
Pennsylvania. This amount includes targeted funding to support medical
surge and the public health workforce. The PHEP may be found at
www.bt.cdc.gov/cotper/coopagreement.
Generally, this program has greatly increased the preparedness
capabilities of public health departments:
All States can receive and evaluate urgent disease reports
24/7, while in 1999 only 12 could do so.
All States now conduct year-round influenza surveillance.
The number of State and local public health laboratories
that can detect biological agents as members of CDC's
Laboratory Response Network (LRN) has increased to 110 in 2007,
from 83 in 2002. For chemical agents, the number increased to
47, from 0 in 2001. Rather than having to rely on confirmation
from laboratories at CDC, LRN laboratories can produce
conclusive results. This allows local authorities to respond
quickly to emergencies.
All States have trained public health staff roles and
responsibilities during an emergency as outlined in the
Incident Command System, while in 1999 only 14 did so.
All States routinely conduct exercises to test public health
departments' ability to respond to emergencies. Such exercises
were uncommon before PHEP funding.
PHEP has helped to improve the preparedness capabilities of the
State of Pennsylvania through the following initiatives:
Citizen Education and Preparedness Outreach Campaign (CEPOC)
The Pennsylvania Department of Health (PA DOH), Office of Public
Health Preparedness (OPHP) along with the Pennsylvania Emergency
Management Agency (PEMA) and other State agencies worked together to
implement a multi-year CEPOC. This CEPOC is designed to reach all
Pennsylvanians and provide all-hazards public health education
information. The focus of the PA DOH CEPOC is to mitigate mortality and
morbidity and minimize public health infrastructural damages during a
manmade or natural event.
The Pennsylvania Emergency Management Agency (PEMA), with support
from the Pennsylvania Department of Health (PA DOH) and other State
agencies, created a centralized emergency planning resource repository
that provides consistent preparedness messaging in the Commonwealth,
called READYPA. READYPA provides direction and information to citizens
and communities on the importance of being prepared by highlighting
personal preparedness strategies. The theme of the campaign is: Be
Informed, Be Prepared, and Be Involved. A phone line, 1-888-9-READYPA,
was launched in January 2009.
Special Medical Needs Response Plan
Pennsylvania drafted a Special Medical Needs Response Plan--a
comprehensive, standardized special medical needs response plan with a
county and regional approach that is completely integrated into
Pennsylvania's emergency response program. It is designed to guide
local response efforts, identify the population, their location, and
their needs and resources for an effective and timely emergency
response. Temple University has pilot tested the draft Special Medical
Needs Evacuation and Response template and Special Populations Planning
Guide for first responders. The guide is designed to be a tool for
local responders in developing a localized plan specific to the
communities they serve. With this tool, the local, regional, and State
response agencies will have a framework to further assist in developing
localized plans for their target communities with special needs,
including providing adequate staffing during an emergency, and allowing
sufficient time to train the responders
communication
HHS employs a variety of mechanisms to ensure that communications
with States remains operational at all times. Most of our
communications are directed to the State Health Departments who then
distribute that information to local organizations. Our Regional
Emergency Coordinators are in regular communications with their State
counterparts. Our HPP leadership conducts monthly calls with their
grant recipients, usually the State HPP project officer, monthly.
During responses within a State, ASPR increases the frequency of the
communications with the States. We have liaison officers in the State
EOC. After responses, we conduct after-action sessions to assess our
response and we invite State/local representatives to provide input.
With regard to communications with clinicians, HHS conducts
teleconferences with providers who can then speak with subject matter
experts. For example, during the on-going H1N1 pandemic, CDC conducted
calls with providers to answer questions regarding the disease and its
treatment. ASPR held teleconferences with critical care clinicians to
discuss the care of patients who required intensive care. HHS also
conducted calls with CMS to inform hospitals about their options
regarding alternate care sites and other capacity expanding mechanisms.
Other mechanisms to communicate with our State, local, Tribal, and
territorial partners incorporate electronic means. CDC has both the
Health Alert Network, which sends out electronic notices of health-
related issues of interest and the Epi-X program, which notifies State
epidemiologists of disease outbreaks of interest and provides an
electronic bulletin board for them to hold discussions.
Both CDC and ASPR have websites which contain updated information
on preparedness and response. Individual providers, as well as the
general population have access to critical information relating to
preparedness and response.
HAvBED
HHS also has developed a mechanism to maintain situational
awareness of hospital status. The ``Hospital Available Beds in
Emergencies and Disasters'' (HAvBED) was developed by HPP in
conjunction with the Agency for Healthcare Research and Quality as a
means of collecting surge bed status in the time of a disaster. Use of
this system (or compatible systems) is required by the Hospital
Preparedness Program. Originally, this system required reports of
available beds, including a count of available adult and pediatric
general beds and ICU beds, to State and HHS emergency operations
centers within 4 hours of request. During the H1N1 pandemic, the system
was modified to collect information that might indicate health care
system stress, as reflected by emergency department status and
anticipated supply shortages. This information has been collected
weekly. Within 48 hours of collection, information is analyzed and any
concerns are passed back to State Health Departments through the RECs
for action.
The declaration by the President of H1N1 as a National emergency,
coupled with the Secretary's Declaration of a Public Health Emergency,
provides authority under section 1135 of the Social Security Act, to
temporarily waive legal provisions or modify certain Medicare,
Medicaid, CHIP, and HIPAA requirements if necessary, in order to
provide hospitals with needed flexibility in emergency or pandemic
situations to deal more effectively with patient surge needs rather
than restrictive paperwork. This move has been welcomed by local
hospitals, many of whom can now make requests of CMS for 1135 waivers
in the event that increased patient loads due to H1N1 affect the
availability of health care items and services. These requests are
reviewed by CMS within 24 hours and can be granted retroactively to the
beginning of the emergency period (that is, back to October 23, 2009)
if necessary.
homeland security presidential directive-21
Homeland Security Presidential Directive (HSPD)-21, ``Public Health
and Medical Preparedness,'' established a National Strategy for Public
Health and Medical Preparedness. The Strategy aims to improve the
Nation's ability to plan for, respond to, and recover from public
health and medical emergencies and calls for the continued development
of a robust infrastructure--including health care facilities,
responders, and providers--which can be drawn upon in the event of an
emergency. HSPD-21 also requires the ``establishment of a robust
disaster health capability requires us to develop an operational
concept for the medical response to catastrophic health events that is
substantively distinct from and broader than that which guides day-to-
day operations.''
To this end, HHS has also led the development of the National
Health Security Strategy (NHSS), the first comprehensive strategy
focusing specifically on protecting people's health in the case of an
emergency (www.hhs.gov/aspr/opsp/nhss). Called for in PAHPA, the NHSS
is designed to strengthen and sustain health and emergency response
systems and build community resilience thereby enhancing medical surge
capacity at all levels of community. The NHSS calls for active
collaboration among individuals, families, and communities (including
private sector and all governmental, non-governmental, and academic
organizations) to implement strategies to prevent, protect against,
respond to, and recover from any type of large-scale incident having
health consequences.
The National Health Security Strategy addresses additional steps
that must be taken to ensure that adequate medical surge capacity,
including a sufficiently sized and competent workforce available to
respond to health incidents; a sustainable medical countermeasure
enterprise sufficient to counter health incidents is fostered; and
increased attention to building more resilient communities and
integrating the public, including at-risk individuals, into National
health security efforts. HHS is also leading the development of an NHSS
Implementation Plan to identify the steps that are needed to enhance
medical surge capacity.
Emergency Care Coordination Center
The Emergency Care Coordination Center (ECCC) was established in
response to the Department's identification of the pressing needs of
the Nation's emergency medical system (www.hhs.gov/aspr/opeo/eccc). The
ECCC takes a regional approach to assist and strengthen the U.S.
Government's efforts to promote Federal, State, Tribal, local, and
private sector collaboration and to support and enhance the Nation's
system of emergency medical care delivery. It is a collaborative effort
involving the DoD, DHS, Department of Transportation and Department of
Veterans Affairs. Its vision is exceptional daily emergency care for
all persons of the United States and its mission is to promote Federal,
State, local, Tribal, and private sector collaboration to support and
enhance the Nation's emergency medical care.
The ECCC strengthens our Nation's ability to respond to mass
casualty events. The ECCC assists the U.S. Government with policy
implementation and guidance on daily emergency care issues and promote
both clinical and systems-based research. Through these efforts, ASPR
and its Federal partners will improve the effectiveness of pre-hospital
and hospital based emergency care by leveraging research outcomes,
private sector findings, and best practices. The ECCC promotes improved
daily emergency care capabilities to improve the resiliency of our
local community health care systems.
conclusion
Our work to enhance medical surge continues to move forward. The
responsibility for medical surge capacity is shared at the local,
State, and Federal levels and includes private as well as public
partners. HHS has provided funding and guidance to our Pennsylvania
State partners and we have actively engaged in workshops and exercises
with our State and local partners to advance preparations. With the
leadership and support of Congress, we have made substantial progress.
The threats to public health remain real, and we have much left to do
to ensure that we meet our mission of a Nation prepared.
Mr. Carney. Thank you, Dr. Pane. Ms. Fitzgerald for 5
minutes, please.
STATEMENT OF SHANNON FITZGERALD, DIRECTOR, PENNSYLVANIA OFFICE
OF PUBLIC HEALTH PREPAREDNESS, PENNSYLVANIA DEPARTMENT OF
HEALTH
Ms. Fitzgerald. Okay. Thank you, and, good morning,
Chairman Carney and Ranking Member Mr. Bilirakis. My name is
Shannon Fitzgerald, and I am the Director of the Office of
Health Preparedness with the Pennsylvania Department of Health
as the department's lead on matters related to public health
preparedness and response. Secretary Everette James has asked
me to address the important issue of medical surge capacity and
answer any questions you may have. Thank you very much for this
opportunity. Medical surge capacity is a broad subject with
many areas of focus, and today I am going to focus on four
specific areas of medical surge capacity and how the
Pennsylvania Department of Health has contributed to enhancing
medical surge capacity across the State.
The four areas are defined in a 2008 GAO report authored by
Ms. Bascetta sitting next to me here, and they include
increasing hospital capacity, including beds, workforce,
equipment, and supplies; identifying and operating alternative
care sites when hospital capacity is overwhelmed; registering
and credentialing volunteer medical professionals; and planning
for appropriate altered standards of care in order to save the
most lives in a mass casualty event. The department works
diligently with health care, Government, and non-profit
partners to build and support medical surge capacities and
capabilities throughout the State.
The first area of medical surge capacity that I will
discuss is increasing hospital capacity. Since 2002, the
Pennsylvania Department of Health has received funding from the
Department of Health and Human Services, their hospital
preparedness program, and we have pushed significant funding
directly out to hospitals in order to improve individual
hospital capacity. In 2009-2010, we received over $14 million
in funding and almost 60 percent was distributed directly to
175 hospitals with emergency departments. Hospitals over the
past several years have used this funding to improve their
preparedness at the hospital level and need the hospital
preparedness program capabilities, including personal
protective equipment and decontamination and improving
pharmaceutical caches, et cetera.
In addition, we have used our funding to enhance our
laboratory capacity and have purchased two bio-safety level
three mobile laboratories which can be deployed anywhere within
the Commonwealth within a matter of hours. Verifying the
availability of hospital resources during an emergency is
essential, and the way that we identify resources such as
equipment and supplies, as well as hospital beds, is through a
State-owned and operated database called FRED, or our Facility
Resource Emergency Database. We use the system FRED to collect
data and upload it into the Federal HAvBED system during the
2009 H1N1 influenza response.
Another example of how we have contributed to increasing
medical surge capacities through a burn training program, and
we have established both a burn training program, as well as
purchased additional burn supplies in the northeastern part of
the State, and there has been 24 burn carts that have been
pushed out throughout the northeastern part of the State which
really allows through the training and the burn cart allows
patients to receive critical care within the first 24 hours
prior to being able to be transported to a burn facility.
The second area of medical surge capacity is alternate care
sites, and we have purchased mobile medical assets, including
portable hospitals and medical surge trailers, which can serve
as alternate care sites wherever there is a need in the
Commonwealth. Currently, we have eight portable hospital
systems and 19 medical surge trailers that can be deployed on a
moment's notice. The third area of medical surge capacity is
volunteer medical professionals. Pennsylvania is meeting the
Federal ESAR-VHP requirement to recruit and train medical
professionals through out State Emergency Registry of
Volunteers in Pennsylvania or SERVPA. Currently, we have over
6,400 registered volunteers and 63 percent of those are medical
professionals. We recently deployed several of them to assist
us with our H1N1 at mass vaccination clinics.
Another personal resource that we support through our
Federal funding is the State Medical Response Team, and that is
a team that has purchased equipment and supplies and they train
personnel and they are ready to deploy. They are similar to the
Federal DMAP program but it is a local resource. We also have a
robust medical surge personnel resource through our Emergency
Medical Services system. Over 54,000 EMS personnel assist with
over 1.8 million patient transports per year. We used our
Emergency Medical Services personnel to help supply surge
resources once again during the 2009 H1N1 event. They assisted
with mass vaccinations at our clinics.
The final area of surge capacity is altered standards of
care, and we are in the process of finalizing a nine volume
medical surge capacity guidance document that is intended to
provide a coordinated State-wide health and medical surge
strategy and direction to the wide audience of health care
practitioners, health care facility or systems administrators,
community-based public health and public safety partners and
responders. We plan on rolling out this guidance document later
this spring, and one of the volumes addresses the very
important piece of modified delivery of care with health care
and scarce resources. So we look forward to rolling out this
guidance document and then working with our partners throughout
the State to train on it and to hold discussions on how to
implement medical surge and altered standards of care State-
wide. Thank you very much for this opportunity to present
today. I am happy to take your questions.
[The statement of Ms. Fitzgerald follows:]
Prepared Statement of Shannon Fitzgerald
January 25, 2010
Good morning Chairman Carney and Members of the House Committee on
Homeland Security's Subcommittee on Management, Investigations, and
Oversight. My name is Shannon Fitzgerald and I am the Director of the
Office of Public Health Preparedness, with the Pennsylvania Department
of Health (department). As the department's lead on matters related to
public health preparedness and response, Secretary Everette James has
asked me to address the important issue of medical surge capacity and
answer any questions that you may have. Thank you for this opportunity.
Medical surge capacity is a broad subject with many areas of focus.
I am going to focus on four specific areas of medical surge capacity
and how the Pennsylvania Department of Health has contributed to
enhancing medical surge capacity across the State. The four areas are
defined in the June 2008 United States Government Accountability Office
report to Congressional Requests titled, ``Emergency Preparedness,
States are planning for medical surge, but could benefit from shared
guidance for allocating scarce medical resources.'' The four areas
include: ``(1) increasing hospital capacity, including beds, workforce,
equipment, and supplies; (2) identifying and operating alternate care
sites when hospital capacity is overwhelmed; (3) registering and
credentialing volunteer medical professionals; and (4) planning for
appropriate altered standards of care in order to save the most lives
in a mass casualty event.''\1\
---------------------------------------------------------------------------
\1\ GAO-08-668 ``Emergency Preparedness: States are planning for
medial surge, but could benefit from shared guidance for allocating
scarce medical resources,'' June 2008.
---------------------------------------------------------------------------
The department works diligently with health care, Government, and
non-profit partners to build and support medical surge capacities and
capabilities throughout the State.
The first area of medical surge capacity that I will discuss is
increasing hospital capacity. Since 2002 Pennsylvania has received the
Department of Health and Human Services, Office of the Assistance
Secretary for Preparedness and Response, Hospital Preparedness Program
(HPP) funding. This funding must be utilized to exercise and improve
preparedness plans for all-hazards and enhance the capacities and
capabilities of health care systems. In the 2009-2010 HPP grant year,
the department received over $14 million in HPP funding. Almost 60% of
the funding was distributed to 175 hospitals with emergency departments
for preparedness activities. The hospitals are required to utilize this
funding to meet the HPP overarching requirements that include, National
Incident Management Systems, Needs of At-Risk Populations, Education
and Preparedness Training and Exercises, Evaluation and Corrective
Actions; Level One Sub-Capabilities including, Interoperable
Communication Systems, Tracking of Bed Availability, Emergency System
for Advance Registration of Volunteer Health Professionals also called
ESAR-VHP, Fatality Management, Medical Evacuation/Shelter in Place,
Partnership/Coalition Development; and Level Two-Sub-Capabilities
including, Alternate Care Sites, Mobile Medical Assets, Pharmaceutical
Caches, Personal Protective Equipment, Decontamination, Medical Reserve
Corps and Critical Infrastructure Protection. Hospitals have utilized
the HPP funding since 2002 to meet these objectives and to purchase
medical surge items including, but not limited to the following:
supplies and equipment to support medical surge activities
(i.e., beds, cots, ventilators, linens, evacuation sleds and
chairs, trauma kits, burn supplies, utility carts, wheel
chairs, automatic external defibrillators, and suction units);
negative pressure isolation supplies and equipment;
pharmaceutical caches of medications to provide prophylaxis
to staff members and their families during disaster situations;
communication and information technology equipment (i.e.,
radios, telephones, computer equipment, televisions, electronic
notification boards);
facility support supplies and equipment (i.e. emergency
generators, incident command needs, mobile medical assets,
portable lighting, security items, trailers);
personal protective equipment for staff;
decontamination supplies and equipment;
education and training expenses;
exercise expenses;
laboratory surge equipment; and
conduct emergency preparedness and response planning.
The department has enhanced our laboratory capacity with the
purchase of two biosafety level 3 (BSL-3) mobile laboratories which can
be deployed to any site in the Commonwealth within hours. The mobile
laboratories are equipped with robotic prep-stations and real-time
polymerase chain reaction (PCR) instrumentation for rapid pathogen
identification. All of the equipment can be powered via landline or on-
board diesel generators. The mobile laboratories can conduct swine and
avian influenza testing and test for select agents, toxins, and
chemical terrorism agents.
Verifying the availability of hospital resources during an
emergency is essential. The department uses the State-owned and
operated Facility Resource Emergency Database (FRED) to notify
hospitals of potential events and to collect real-time data from
hospitals, using a web-based application. The system can collect any
data required for the event, including the availability of various
types of hospital beds, including adult intensive care beds, medical/
surgical beds, burn beds, pediatric beds, etc. The system can also
collect data on the number of ventilators and pharmaceuticals
available. The department tests this system on a monthly basis and
utilizes this system to collect the bed data (Hospital Available Beds
for Emergencies and Disasters/HAvBED) required by the U.S. Department
of Health and Human Services during the 2009 H1N1 influenza response.
Another example of how the department has contributed to increasing
medical surge capability is through a burn training program. The
department has provided funding to support burn training for over 1,200
medical providers throughout the Commonwealth. The 8-hour course is
designed to ensure pre-hospital and hospital personnel are ready in the
event of accidents or disasters involving burn injury. The course
provides guidelines in the assessment and management of the burn
patient during the first 24 hours post-injury until the patient can be
transported to one of the limited number of burns beds in the
Commonwealth or country. The Department has also provided funding for
the creation of a burn surge program in the Northeast region of
Pennsylvania. This program provides a higher level of burn care at 24
regional hospitals and three mobile surge facilities in the Northeast
region. The grant funded the creation of 27 burn carts for use at these
hospitals and facilities. Each cart contains supplies and information
to care for up to three moderately burned patients for 3 days. Training
on the use of the carts for burn care was provided by the Lehigh Valley
Health Network's Regional Burn Center to each hospital receiving a
cart.
The second area of medical surge capacity is alternate care sites.
The Pennsylvania Department of Health has purchased mobile medical
assets, including portable hospitals and medical surge trailers, which
can serve as alternate care sites wherever there is a need in the
Commonwealth.
The Department has purchased eight portable hospital systems to
increase the medical surge capacity in the Commonwealth. Each of these
systems comes in two 28-foot trailers and contains all of the supplies
and equipment needed to set up 50 hospital beds in a tent capable of
providing a negative pressure environment. Each system has the
materials necessary to care for up to 350 patients (or one patient per
bed for 1 week). The portable hospitals increase the State-wide bed
capacity by 400 beds and can be set up anywhere in the Commonwealth,
thus increasing the number of available alternate care sites and
allowing flexibility for the alternate care sites to be placed where
most needed.
The eight systems are stored in geographic locations throughout the
State and can been entirely deployed within 90 minutes of arrival on
the scene utilizing a crew of not more than six individuals. Each
system includes the following medical surge equipment and supplies:
supplies for receiving and classification (i.e., office
supplies, tables, chairs, walkie talkies, and megaphones);
medical and patient care supplies;
mortuary supplies;
diagnostic supplies;
housekeeping equipment and miscellaneous supplies;
transportation system (one climate controlled trailer for
medical supplies and equipment and one trailer for support
materials); and
support equipment (i.e., hospital tents, heater, negative
pressure capability, generators, waste systems, water systems,
and oxygen systems).
The Pennsylvania Department of Health has also purchased nineteen
medical surge trailers. Each of these trailers contain the supplies and
equipment needed to set up 50 medical cots in a fixed facility. The
medical equipment and supplies are assembled, stored in trailers, and
pre-deployed to geographic locations throughout the Commonwealth. This
resource utilizes a standard-size basketball court, as well as the
perimeter of the court to place additional supplies or equipment. Each
trailer will include the following medical surge equipment and
supplies:
supplies for receiving and classification (i.e., office
supplies, table, chairs);
medical and patient care supplies; and
transportation system (trailer).
In addition to the mobile medical assets mentioned in this
testimony, most hospitals have identified alternate care sites for
short-term and long-term emergencies. Many hospital designated sites
are located within the hospital campus or hospital-owned facilities off
campus.
To support medical surge operations within a hospital setting and
at alternate care sites, the department has tested and is in the
process of implementing a patient tracking system. The Commonwealth-
wide patient tracking system relies on bar-coded bands that will be
placed on patients at a mass casualty scene. The bands are read by a
scanner and important limited patient information will be loaded into a
web-based application viewable by emergency response partners.
The third area of medical surge capacity is volunteer medical
professionals. The Pennsylvania Department of Health is meeting the
Federal Emergency System for Advance Registration of Volunteer Health
Professionals (ESAR-VHP) requirement through its State Emergency
Registry of Volunteers in Pennsylvania (SERVPA) program. Pennsylvania
has established an on-line registry for volunteers interested in
responding to or assisting with a disaster or other emergency. The
registry collects basic information from volunteers in advance of an
emergency response situation. The registry verifies health care
professional licenses with an automated link with the Department of
State's licensure registry. SERVPA currently has 6,400 registered
volunteers. Over 63% of the volunteers registered are health care
personnel. In addition, Pennsylvania has 14 Medical Reserve Corps (MRC)
teams with almost 3,000 volunteers.
Another personnel resource to support medical surge needs are the
three State Medical Response Teams (SMRTs) which are supported by the
department. The SMRTs have purchased supplies and equipment and have
trained personnel that are ready to deploy to a mass casualty or other
emergency within a couple of hours to assist with patient triage and
patient care. The SMRT from southeastern Pennsylvania deployed to the
G-20 event in Pittsburgh in 2009. The combination of resources provided
by the SMRT and an EMS Strike Team could have provided patient support
for up to 350 patients per hour, including 24 burn patients, without
tapping any of the local medical and hospital resources.
Pennsylvania has a robust medical surge personnel resource within
the emergency medical services (EMS) system. Over 54,000 EMS personnel
assist over 1.8 million patients per year. The EMS system is organized
into 16 Regional EMS Councils, 1,014 ambulance services, 517 quick
response services and 63 air ambulances. The Department supports 150
EMS Strike Teams made up of six EMS personnel each. These Strike Teams
can be taken out of service and deployed without impacting local
service delivery. Several EMS Strike Teams were deployed to Louisiana
to support the efforts to respond to Hurricanes Katrina (2005) and
Gustov (2008). EMS personnel have been trained on how to stand up and
operate the portable hospitals and medical surge trailers and are the
first line of personnel to be deployed with these systems.
The department deployed many of these volunteer health professional
resources to assist with the H1N1 public health vaccination clinics
during the 2009 H1N1 influenza pandemic.
The combination of these volunteer and professional groups, and
other strategies employed by hospitals, including having staff work 12-
hour shifts, provide an extensive network of trained personnel to
support a medical surge event.
The final area of medical surge capacity is altered standards of
care. The Pennsylvania Department of Health is in the process of
finalizing a nine-volume (chapter) medical surge capacity guidance
document intended to provide a coordinated, State-wide health and
medical surge strategy guidance and direction to a wide audience,
including health care practitioners, health care facility or system
administrators, community-based public health and public safety
planners and responders, volunteers, as well as local, regional, and
State agencies. All nine volumes have been drafted and vetted through a
multidisciplinary working group consisting of representatives from
public health, emergency management, and hospital. The following
subject areas are covered in the nine volumes:
Volume I: System of Systems Approach: A comprehensive
overview;
Volume II: Management System: The seamless integration of
multiple levels of medical direction, control, communications,
and coordination;
Volunteer III: Alternate Care Sites: The use of a community-
based triage system to maximize load-sharing and reduce surge
pressures;
Volume IV: Modified Delivery of Healthcare with Scarce
Resources: Providing the best possible medical care to the
largest number possible;
Volume V: Transportation System: Building depth and
redundancy for Emergency Medical Services (EMS), mortuary
affairs, and vendor-managed materiel movement throughout the
system and among patient care facilities;
Volume VI: Resource Management System: Measures to ensure
protracted and sustained operations of health care facilities
and alternate care sites;
Volume VII: Mass Fatality Management System: Leveraging
community mortuary affairs assets for the dignified and
environmentally safe handling and disposition of remains;
Volume VIII: Community Outreach and Education System:
Coordinating a mutually supportive public information network
and campaign to achieve desired results; and
Volume IX: Behavioral Health Support System: Providing
comfort and psychological care to responders, patients, and
families.
Volume IV addresses the modified delivery of health care with
scarce resources. It is intended to assist health care organizations in
preparing for emergency situations where resources are inadequate to
meet the necessary health care needs in the usual manner, compelling a
change in health care delivery strategy. The objectives for modified
health care delivery include the following:
maintain a physically and medically safe environment for
staff, current patients, and visitors, and protect the
functional integrity of the health care organization;
achieve and maintain optimal medical surge capacity and
capability with available resources;
modify health care delivery, through managed change, to
maintain a safe environment and achieve the best possible
medical outcomes; and,
return to normal operations as rapidly as possible and
return response resources to ready status.
In addition to the medical surge guidance document, the
department's Emergency Operations Plan describes Pennsylvania's plan
for facilitating the organization, mobilization, and operation of
health resources in response to natural or man-made incidents,
including a medical surge capacity annex describing the operations plan
for the portable hospital systems and medical surge trailers. The
department works closely with heath care partners to develop,
implement, and support emergency preparedness trainings and exercises
that demonstrate medical surge capacity.
Building and sustaining medical surge capacity is a multi-
jurisdictional effort requiring leadership and coordination. We will
continue to work with our partners at the Federal, State, and local
level to collaborate on medical surge capacity preparedness activities.
On behalf of Secretary James, thank you for inviting the Department
of Health to present this testimony. I am happy to answer your
questions.
Mr. Carney. Thank you, Ms. Fitzgerald. Ms. Bascetta, 5
minutes, please.
STATEMENT OF CYNTHIA A. BASCETTA, DIRECTOR, HEALTH CARE,
GOVERNMENT ACCOUNTABILITY OFFICE
Ms. Bascetta. Good morning, Mr. Chairman, and Mr.
Bilirakis. I am very pleased to be here today to discuss GAO's
work on emergency preparedness, which we put on our list of
urgent issues last year. As you know, the use of anthrax is a
deadly weapon in the wake of the attack on the World Trade
Center, Hurricane Katrina, pandemic flu, and potential for
other disasters have raised concern about the ability of our
Nation's health care systems to respond to natural and man-made
mass casualty events. In such events, local or regional health
care systems may be overwhelmed and unable to deliver services
consistent with established standards of care. The ability of
health care systems to surge was the subject of our June, 2008
report and is the basis for my remarks today.
We examined Federal support to the States to prepare for
the four key components and again their increasing hospital
capacity, operating alternate care sites, mobilizing volunteers
and following altered standards of care, which I would now like
to refer to as crisis standards of care. This is the new term
for this. It was recently issued in an IOM report, Institute of
Medicine, report. As you know, the Department of Homeland
Security has the overall responsibility for managing National
emergency preparedness and the Secretary of HHS is the lead for
all Federal public health and medical responses to public
health emergencies including that surge.
States have the important responsibility for producing
emergency preparedness plan in coordination with local and
regional entities and both DHS and HHS are responsible for
supporting those efforts. DOD and VA also assist State and
local governments under certain conditions. To do our work, we
focused on the hospital preparedness program and guidance from
the Agency for Health Care Research and Quality. We analyzed
cooperative agreements and mid-year progress reports for 20
States, and we selected two States from each of HHS' ten
regions, the ones with the most and the least hospital
preparedness funding. We included Pennsylvania in our sample
because it had the most funding for region three from HHS, and
for this statement we also updated the status of HHS' response
to our recommendation.
We found that many States have made progress in preparing
for medical surge but also reported significant challenges. All
20 were developing bed reporting systems and most were
coordinating with DOD and VA medical facilities to expand the
number of hospital beds. At the same time, shortages of medical
professionals raised some significant concerns about staffing
those beds. Similarly, almost all of the States in our review
were selecting facilities such as schools and churches for
alternate care sites. Some, including Pennsylvania, also
reported purchasing medical mobile facilities as you have just
heard, and many States also reported that they developed plans
for equipping and staffing their alternate care sites.
However, they told us they needed guidance and assurance
from CMS that they would be reimbursed for care provided at
alternate care sites. CMS officials told us that they prefer to
approve payment on a case-by-case basis after visiting sites
because those facilities are not accredited. Regarding
volunteers, most States reported that they had begun
registering volunteers by profession in electronic registries
although they had not all checked the volunteers' credentials.
They were concerned that some medical volunteers might be
reluctant to join a State registry if National deployment were
to become a possibility. Other States also reported double
counting of volunteers and more than one database, such as the
Medical Reserve Corps and Disaster Medical Assistance Teams.
In contrast to the progress made on the first three medical
surge components only 7 of the 20 States at the time of our
review had adopted or were drafting crisis standards of care.
Many States reported the difficulty of addressing medical,
legal, and ethical issues involved in allocating scarce
resources such as pharmaceuticals and ventilators during a
disaster. Some States reported using guidance from AHRQ but
most reported that more Federal guidance would be helpful in
deciding how to make these life and death decisions. We
recommended that HHS serve as a clearinghouse for sharing
crisis standards of care guidelines developed by individual
States and medical experts.
In commenting on our draft report, HHS was silent on our
recommendation but we are pleased to report that HHS has
recently taken steps to design such a clearinghouse and in
addition they funded an IOM study that I referred to earlier.
It was published in September, 2009 and provides guidance for
establishing crisis standards of care. I would be happy to
answer any questions you have.
[The statement of Ms. Bascetta follows:]
Prepared Statement of Cynthia A. Bascetta
Mr. Chairman and Members of the subcommittee: I am pleased to be
here today to discuss our work examining both the Federal assistance
provided to States and the States' own efforts to help build the
``surge capacity'' of the Nation's health care system to respond to
mass casualty events. The September 11, 2001, terrorist attacks on the
World Trade Center and the Pentagon, the anthrax incidents during the
fall of 2001, and the H1N1 influenza pandemic of 2009 have raised
public awareness and concern about the ability of the Nation's health
care systems \1\ to respond to bioterrorism \2\ and other mass casualty
events.\3\ In a mass casualty event the ability of local or regional
health care systems to deliver services consistent with established
standards of care \4\ could be compromised, at least in the short term,
because the volume of patients would far exceed the available hospital
beds, medical personnel, pharmaceuticals, equipment, and supplies. The
Nation's health care system was tested by last year's H1N1 pandemic and
may be challenged to respond to a large-scale public health emergency
if there is a resurgence of the H1N1 influenza virus or some other
strain of influenza in 2010.
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\1\ By health care systems, we mean both public health and medical
systems, including hospitals.
\2\ A bioterrorism attack is the deliberate release of viruses,
bacteria, or other germs (agents) used to cause illness or death in
people, animals, or plants. These agents are typically found in nature,
but it is possible that they could be changed to increase their ability
to cause disease, to make them resistant to current medicines, or to
increase their ability to be spread into the environment. Biological
agents can be spread through the air, through water, or in food.
\3\ A mass casualty event is a public health or medical emergency
that could involve thousands, or even tens of thousands, of injured or
ill victims.
\4\ A standard of care is the diagnostic and treatment process that
a provider should follow for a certain type of patient or illness, or
certain clinical circumstances. It is how similarly qualified health
care providers would manage the patient's care under the same or
similar circumstances.
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Following a mass casualty event, health care systems would need the
ability to ``surge,'' that is, to adequately care for a large number of
patients or patients with unusual or highly specialized medical needs.
Providing such care would require the allocation of scarce resources
and could occur outside of hospitals and other normal health care
delivery sites. Through literature reviews and interviews with experts
and professional associations, we identified four key components
related to preparing for medical surge in a mass casualty event: (1)
Increasing hospital capacity, including beds, workforce, equipment, and
supplies; (2) identifying and operating alternate care sites \5\ when
hospital capacity is overwhelmed; (3) registering and credentialing
volunteer medical professionals; and (4) planning for appropriate
altered standards of care \6\ in order to save the most lives in a mass
casualty event.
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\5\ Alternate care sites deliver medical care outside of hospital
settings for patients who would normally be treated as inpatients.
\6\ The term ``altered standards'' generally means a shift to
providing care and allocating scarce equipment, supplies, and personnel
in a way that saves the largest number of lives, in contrast to the
traditional focus of treating the sickest or most injured patients
first. For example, it could mean applying principles of field triage
to determine who gets what kind of care, changing infection control
standards to permit group isolation rather than single-person isolation
units, changing who provides various kinds of care, or changing privacy
and confidentiality protections temporarily.
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Federal and State entities both play roles in preparing for
emergency preparedness. The Department of Homeland Security (DHS) has
the overall Federal responsibility under the Homeland Security Act of
2002 for managing National emergency preparedness.\7\ In December 2006,
the Congress passed the Pandemic and All-Hazards Preparedness Act
(PAHPA). PAHPA designated the Secretary of Health and Human Services as
the lead official for all Federal public health and medical responses
to public health emergencies, including medical surge.\8\ Under the
Federal plan for responding to emergencies,\9\ States have
responsibility for producing emergency preparedness plans in
coordination with regional and local entities, and both DHS and the
Department of Health and Human Services (HHS) are responsible for
supporting their efforts. In addition, the Department of Defense (DOD)
and the Department of Veterans Affairs (VA) are expected to assist
State and local entities in emergencies. A DOD directive authorizes
local military hospitals to coordinate with State and local entities to
plan for emergency preparedness, and DOD hospitals are authorized to
accept civilian patients in a mass casualty event.\10\ VA policies and
procedures allow VA hospitals to participate in State and local
emergency planning, and by statute VA may provide medical care to non-
veterans in a mass casualty event.
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\7\ See Pub. L. No. 107-296, 116 Stat. 2135 (2002).
\8\ Pub. L. No. 109-417, 101, 120 Stat. 2831, 2832 (2006)
(codified at 42 U.S.C. 300hh).
\9\ The National Response Framework details the missions, policies,
structures, and responsibilities of Federal agencies for coordinating
resource and programmatic support to States, Tribes, and other Federal
agencies.
\10\ DOD Directive 3025.1, Military Support to Civil Authorities
4.6.1.2 and 4.5.1 (Jan. 15, 1993).
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My statement today is based largely on our June 2008 report
entitled Emergency Preparedness: States Are Planning for Medical Surge,
but Could Benefit from Shared Guidance for Allocating Scare Medical
Resources \11\ and includes some updated information. In the June 2008
report, we examined the following questions: (1) What assistance has
the Federal Government provided to help States prepare their regional
and local health care systems for medical surge in a mass casualty
event? (2) What have States done to prepare for medical surge in a mass
casualty event? (3) What concerns have States identified as they
prepare for medical surge in a mass casualty event?
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\11\ GAO, Emergency Preparedness: States Are Planning for Medical
Surge, but Could Benefit from Shared Guidance for Allocating Scare
Medical Resources, GAO-08-668 (Washington, DC: June 13, 2008).
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In carrying out the work for our June 2008 report examining what
assistance the Federal Government provided to States to help them
prepare their regional and local health care systems for medical surge
in a mass casualty event, we reviewed and analyzed National strategic
planning documents. We also analyzed reports related to medical surge
capacity issued by various entities, including the Agency for
Healthcare Research and Quality (AHRQ), Centers for Disease Control and
Prevention (CDC), Office of the Assistant Secretary for Preparedness
and Response (ASPR), and the Joint Commission.\12\ In addition, we
obtained and reviewed documents from ASPR to determine the amount of
funds awarded to States through its Hospital Preparedness Program's
cooperative agreements. We also interviewed officials from ASPR, CDC,
and DHS to identify and document criteria and guidance given to States
to plan for medical surge. To determine what States had done to prepare
for medical surge in a mass casualty event, we obtained and analyzed
the 2006 and 2007 ASPR Hospital Preparedness Program cooperative
agreement applications and 2006 mid-year progress reports (the most
current available information at the time of our data collection for
the June 2008 report)\13\ for the 50 States.\14\ We also reviewed the
15 sentinel indicators from these reports.\15\ Although ASPR's 2006
guidance for these mid-year progress reports did not provide specific
criteria with which to evaluate recipients' performance on these
sentinel indicators, we identified criteria to analyze the data
provided for 5 of the indicators related to one of four key
components--hospital capacity--from either ASPR's previous program
guidance or DHS guidance.\16\ In addition, we obtained and reviewed 20
States' emergency preparedness planning documents relating to medical
surge and interviewed officials from these States responsible for
planning for medical surge. We selected the 20 States by identifying 2
States from each of the 10 HHS geographic regions--one with the most
ASPR Hospital Preparedness Program funding and one with the least
funding. These selection criteria allowed us to take into account
population (program funding was awarded using a formula including, in
part, population), geographic dispersion, and different geographic risk
factors, such as the potential for hurricanes, tornadoes, or
earthquakes. We obtained and reviewed DOD and VA policies and
interviewed officials regarding their participation with State and
local entities in emergency preparedness planning and response. To
determine what concerns States identified as they prepared for medical
surge, we interviewed emergency preparedness officials from the 20
States on their efforts related to four key components. We also asked
what further assistance States might need from the Federal Government
to help prepare their health care systems for medical surge. The
information from these interviews is intended to provide a general
description of what the 20 States have done to prepare for medical
surge and is not generalizable to all 50 States. We conducted the
performance audit for the June 2008 report from May 2007 through May
2008, and updated certain information on the status of HHS's actions to
respond to our recommendations by interviewing an HHS official, in
accordance with generally accepted Government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives. A detailed explanation of
our methodology is included in our June 2008 report.
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\12\ The Joint Commission is an independent, non-profit
organization that evaluates and accredits more than 15,000 U.S. health
care organizations and programs, including DOD and VA hospitals.
\13\ The 2006 program year for the Hospital Preparedness Program
was September 1, 2006, to August 31, 2007. The 2007 program year was
September 1, 2007, to August 8, 2008.
\14\ While the Hospital Preparedness Program awards funds annually
to 62 entities--the 50 States; 4 municipalities, including the District
of Columbia; 5 U.S. territories; and 3 Freely Associated States of the
Pacific--we limited our review to the 50 States.
\15\ Sentinel indicators are smaller component tasks of critical
benchmarks, which measure program capacity-building efforts such as
purchasing equipment and supplies and acquiring personnel. For example,
for the benchmark ``Surge Capacity; Beds,'' one of the sentinel
indicators is the number of additional hospital beds for which a
recipient could make patient care available within 24 hours. ASPR
requires that States report on 15 sentinel indicators.
\16\ Two of the 15 indicators--total number of hospitals State-wide
and total population State-wide--were used as denominators to analyze
the 5 indicators.
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In brief, we found that the Federal Government provided funding,
guidance, and other assistance to help States prepare for medical surge
in a mass casualty event. From fiscal years 2002 to 2007, the Federal
Government awarded the States about $2.2 billion through ASPR's
Hospital Preparedness Program to support activities to meet their
preparedness priorities and goals, including medical surge. Further, we
reported that the Federal Government developed, or contracted with
experts to develop, guidance that was provided for States to use when
preparing for medical surge and that ASPR project officers and CDC
subject matter experts were available to provide assistance to States
on issues related to medical surge. In reporting on State activities,
we found that many States had made efforts related to three of the key
components of medical surge, that is, increasing hospital capacity,
planning for alternate care sites, and developing electronic medical
volunteer registries, but fewer had addressed the fourth component,
planning for altered standards of care. For example, in our 20-State
review, we found that all were developing bed reporting systems to
increase hospital capacity and 18 reported that they were in the
process of selecting alternate care sites that used either fixed or
mobile medical facilities. However, fewer of the States--7 of the 20--
had adopted or were drafting altered standards of medical care to be
used in response to a mass casualty event. In reporting on concerns
States identified as they prepared for medical surge, we found that
State officials in the 20 States we surveyed reported that they
continued to face challenges related to all four key components of
medical surge. For example, some States reported that although they
could increase numbers of hospital beds in a mass casualty event, they
were concerned about staffing those beds because of current shortages
in medical professionals, and some States reported that they had not
begun work on altered standards of care guidelines, or had not
completed drafting guidelines, because of the difficulty of addressing
the medical, ethical, and legal issues involved in making life-or-death
decisions in advance of a disaster about which patients would get or
lose access to scarce resources.
To further assist States in determining how they will allocate
scarce medical resources in a mass casualty event, we recommended that
the Secretary of HHS ensure that the department serve as a
clearinghouse for sharing among the States altered standards of care
guidelines that have been developed by individual States or medical
experts. In commenting on a draft of our report in May 2008, HHS, DHS,
DOD, and VA concurred with our findings. HHS was silent regarding our
recommendation. However, in October 2009, an HHS official reported that
the agency was designing a web portal to serve as a clearinghouse on
preparedness and response, with an emphasis on the allocation of scarce
medical resources, in part as a result of GAO's recommendation. In
January 2010, an HHS official reported that efforts to design and
develop the web portal were continuing.
the federal government has provided states with funding, guidance, and
other assistance to prepare for medical surge
In June 2008, we reported that from fiscal years 2002 through 2007,
HHS awarded States about $2.2 billion through ASPR's Hospital
Preparedness Program \17\ to support activities to strengthen their
hospital emergency preparedness capabilities, including medical surge
goals and priorities.\18\ ASPR's 2007 Hospital Preparedness Program
guidance specifically authorized States to use funds on activities such
as the development of a fully operational electronic medical volunteer
registry and the establishment of alternate care sites. We cannot
report State-specific funding for the four key components of medical
surge because State expenditure reports did not disaggregate the dollar
amount spent on specific activities related to these components. During
fiscal years 2003 through 2007, DHS's Homeland Security Grant Program
also awarded the States funds that were used for a broad variety of
emergency preparedness activities and may have included medical surge
activities. However, most of these DHS grant funds were not targeted to
medical surge activities, and States do not report the dollar amounts
spent on these activities.
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\17\ An additional $218 million was provided to four large
municipalities, five U.S. territories, and three Freely Associated
States of the Pacific for a total of approximately $2.5 billion. Over
the 2-year period, fiscal years 2004 and 2005, HHS also awarded an
additional $200,000 to 48 States for electronic medical volunteer
registries development through this program.
\18\ Since January 2006, HHS also had awarded the 62 recipients an
additional $400 million in two phases and a supplement to prepare for a
pandemic influenza outbreak. The funds were awarded to accelerate their
current planning efforts for an influenza pandemic and to exercise
their plans. These funds included $75 million in August 2007 that could
be used, in part, to develop pandemic alternate care sites and to
conduct medical surge exercises.
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The Federal Government developed, or contracted with experts to
develop, guidance for States to use in preparing for medical surge. DHS
developed overarching guidance, including the National Preparedness
Guidelines and the Target Capabilities List. The National Preparedness
Guidelines describes the tasks needed to prepare for a medical surge
response to a mass casualty event, such as a bioterrorist event or
natural disaster, and establishes readiness priorities, targets, and
metrics to align the efforts of Federal, State, local, Tribal, private-
sector, and nongovernmental entities. The Target Capabilities List
provides guidance on building and maintaining capabilities, such as
medical surge, that support the National Preparedness Guidelines. The
medical surge capability includes activities and critical tasks needed
to rapidly and appropriately care for the injured and ill from mass
casualty events and to ensure that continuity of care is maintained for
non-incident-related injuries or illnesses.\19\ In addition, ASPR
provided States with specific guidance related to preparing for medical
surge in a mass casualty event, such as annual guidance for its
Hospital Preparedness Program cooperative agreements, guidance for
developing electronic medical volunteer registries, and guidance to
develop a hospital bed tracking system. For example, ASPR's electronic
medical volunteer registries guidelines provide States with common
definitions, standards, and protocols, which can aid in forming a
National network to facilitate the deployment of medical volunteers for
any emergency among States.
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\19\ For example, one of the activities is to receive and treat
surge casualties. One of the critical tasks associated with this
activity is to ensure adequacy of medical equipment and supplies in
support of immediate medical response operations and for restocking
requested supplies and equipment.
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Additionally, we reported that HHS worked through AHRQ and
contracted with non-Federal entities to develop publications for States
to use when preparing for medical surge. For example, AHRQ published
the document Mass Medical Care with Scarce Resources: A Community
Planning Guide to provide States with information that would help them
in their efforts to prepare for medical surge, such as specific
circumstances they may face in a mass casualty event. This publication
notes that a State may be faced with allocating medical resources
during a mass casualty event, such as determining which patients will
have access to mechanical ventilation. The publication recommends that
the States develop decision-making guidelines on how to allocate these
medical resources. To support States' efforts to prepare for medical
surge, the Federal Government also provided other assistance, such as
conferences and electronic bulletin boards for States to use in
preparing for medical surge. For example, States were required to
attend annual conferences for Hospital Preparedness Program cooperative
agreement recipients, where ASPR provided forums for discussion of
medical surge issues. Furthermore, ASPR project officers and CDC
subject matter experts were available to provide assistance to States
on issues related to medical surge. For example, CDC's Division of
Healthcare Quality Promotion developed cross-sector workshops for local
communities to bring their emergency management, medical, and public
health officials together to focus on emergency planning issues, such
as developing alternate care sites. A detailed list of Federal guidance
and conferences is included in our June 2008 report.
many states have made efforts to increase hospital capacity, plan for
alternate care sites, and develop electronic medical volunteer
registries, but fewer have planned for altered standards of care
In June 2008 we reported that States were making efforts to expand
hospital capacity. We found that more than half of the States met or
were close to meeting the criteria for the five surge-related sentinel
indicators for hospital capacity that we reviewed from the Hospital
Preparedness Program 2006 mid-year progress reports,\20\ the most
recent available data at the time of our analysis for the June 2008
report.\21\ Twenty-four of the States reported that all of their
hospitals were participating in the State's program funded by the ASPR
Hospital Preparedness Program, with another 14 States reporting that 90
percent or more of their hospitals were participating. Forty-three of
the 50 States had increased their hospital capacity by ensuring that at
least one health care facility in each defined region could support
initial evaluation and treatment of at least 10 patients at a time
(adult and pediatric) in negative pressure isolation \22\ within 3
hours of an event. Regarding individual hospitals' isolation
capabilities, 32 of the 50 States met the requirement that all
hospitals in the State that participate in the Hospital Preparedness
Program be able to maintain at least one suspected highly infectious
disease case in negative pressure isolation; another 10 States had that
capability in 90 to 99 percent of their participating hospitals.
Thirty-seven of the 50 States reported meeting the criteria that within
24 hours of a mass casualty event, their hospitals would be able to add
enough beds to provide triage treatment and stabilization for another
500 patients per million population; another 4 States reported that
their hospitals could add enough beds for from 400 to 499 patients per
million population. Finally, 20 of the 50 States reported that all
their participating hospitals had access to pharmaceutical caches that
were sufficient to cover hospital personnel (medical and ancillary),
hospital-based emergency first responders, and family members
associated with their facilities for a 72-hour period; another 6 States
reported that from 90 to 99 percent of their participating hospitals
had sufficient pharmaceutical caches.
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\20\ The 2006 program year was from September 1, 2006, to August
31, 2007; therefore, information provided in the mid-year progress
reports was reported as of March 2007.
\21\ Four of the States we reviewed provided sentinel indicator
information as of April 2007, one State as of August 2007, and another
State as of September 2007.
\22\ Negative pressure isolation rooms maintain a flow of air into
the room to ensure that contaminants and pathogens cannot escape from
the room to other parts of the facility and to protect the health of
workers and other patients.
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We also reported in 2008 that in a further review of 20 States, all
20 States reported that they had developed or were developing bed
reporting systems to track their hospital capacity--the first of four
key components related to preparing for medical surge. Eighteen of the
20 States reported that they had systems in place that could report the
number of available hospital beds within the State. All 18 of these
States reported that their systems met ASPR Hospital Available Beds for
Emergencies and Disasters (HAvBED) standards.\23\ The two States that
reported that they did not have a system that could meet HAvBED
requirements said that they would meet the requirements by August 8,
2008.\24\ We also reported that of the 10 States with DOD hospitals, 9
reported coordinating with DOD hospitals to plan for emergency
preparedness and increase hospital capacity and 8 reported that DOD
hospitals in their State would accept civilian patients in the event of
a mass casualty event if resources were available.\25\ Additionally, of
the 19 States that have VA hospitals, all reported that at least some
of the VA hospitals took part in the States' hospital preparedness
programs or were included in planning and exercises for medical
surge.\26\ VA officials Stated that individual hospitals cannot
precommit resources--specific numbers of beds and assets--for planning
purposes, but can accept nonveteran patients and provide personnel,
equipment, and supplies on a case-by-case basis during a mass casualty
event.\27\ Twelve of the 19 States reported that VA hospitals would
accept or were likely to accept nonveteran patients in the event of a
medical surge if space were available and veterans' needs had been met,
and one State reported that some of its VA hospitals would take
nonveteran patients and others would not.
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\23\ Among other standards, HAvBED systems are required to report
on seven categories of staffed available beds. The seven bed categories
are intensive care, medical and surgical, burn, pediatric intensive
care, pediatric, psychiatric, and negative pressure isolation. HAvBED
systems are also required to report on emergency department diversions,
decontamination facilities available, and ventilators available. ASPR
allows each State to use Hospital Preparedness Program funds to develop
its own bed tracking system as long as the system meets HAvBED
requirements.
\24\ ASPR required all recipients to complete the development of
their bed tracking system by August 8, 2008.
\25\ DOD Directive 3025.1, section 4.5.1 authorizes military
officials to take necessary actions to respond to civilian requests for
assistance in emergencies, which may include accepting civilian
patients. This decision can be authorized by DOD or, in cases of urgent
need, by the commander of the local military hospital.
\26\ VA is authorized to furnish hospital care or medical services
as a humanitarian service to non-VA beneficiaries in emergency cases.
See 38 U.S.C. 1784; 38 CFR 17.37, 17.43, 17.95, 17.102. VA is also
authorized to provide care and services during certain disasters and
emergencies. See 38 U.S.C. 1785; 38 CFR 17.86.
\27\ According to a VA General Counsel memorandum (Guidance on
Entering into Mutual Aid Agreements, July 23, 2003), hospitals can also
enter into mutual aid agreements in which VA hospitals and local
entities agree to assist each other during disasters and emergencies.
These agreements often include provisions to accept patients from other
hospitals if the transferring hospital has an overwhelming number of
patients or if the transferring facility does not have the resources
for patients who require specialized medical treatment. However, these
mutual aid agreements must state that the agreement is limited by
certain VA obligations that may take precedence over the agreement to
assist local hospitals during an emergency, such as VA's obligations
under the National Disaster Medical System and its obligations to
assist DOD during a time of war or National emergency.
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We further reported in June 2008 that 18 of the 20 States reported
that they were in the process of selecting alternate care sites, and
the two remaining States reported that they were in the early planning
stages in determining how to select sites. Of the 18 States, 10
reported that they had also developed plans for equipping and staffing
some of the sites. For example, one State had developed standards and
guidance for counties to use when implementing fixed alternate care
sites and had stockpiled supplies and equipment for these sites.
Another State, which expects significant transportation difficulties
during a natural disaster, had acquired six mobile medical tent
facilities of either 20 or 50 beds that were stored at hospital
facilities across the State. One of the two States that were in the
early planning stages was helping local communities formalize site
selection agreements, and the second State had drafted guidance for
alternate care sites.
Our June 2008 report also noted that 15 of the 20 States reported
that they had begun registering medical volunteers and identifying
their medical professions in an electronic registry, and the remaining
5 States were developing their electronic registries and had not
registered any volunteers. Officials from 4 of the 5 remaining States
that had not begun registering volunteers reported that they
anticipated registering them. An official from the other State reported
that State officials did not know when they would begin to register
volunteers. Of the 15 States that reported they were registering
volunteers, 12 reported they had begun to verify the volunteers'
medical qualifications, though few had conducted the verification to
assign volunteers to the highest level, Level 1. At Level 1, all of a
volunteer's medical qualifications, which identify his or her skills
and capabilities, have been verified and the volunteer is ready to
provide care in any setting, including a hospital.
In our 20-State review of efforts related to the fourth key
component, we reported that 7 States had adopted or were drafting
altered standards of care for specific medical issues. Three of the 7
States had adopted some altered standards of care guidelines. For
example, one State had prepared a standard of care for the allocation
of ventilators in an avian influenza pandemic, which one State official
reported would also be applicable during other types of
emergencies.\28\ Another State issued guidelines in February 2008 for
allocating scarce medical resources in a mass casualty event that call
for suspending or relaxing State laws covering medical care and for
explicit rationing of health care to save the most lives, and required
that the same allocation guidelines be used across the State. Of the 13
States that had not adopted or drafted altered standards of care, 11
States were beginning discussions with State stakeholders, such as
medical professionals and lawyers, related to altered standards of
care, and 2 States had not addressed the issue. One State reported that
its State health department planned to establish an ethics advisory
board to begin discussion on altered standards of care guidelines.
Another State had developed a ``white paper'' discussing the need for
an altered standards of care initiative and planned to fund a symposium
to discuss this initiative.
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\28\ A ventilator mechanically moves oxygen into and out of the
lungs of a patient who is physically unable to breathe on his or her
own, or whose breathing is insufficient to maintain life.
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states reported concerns related to all four key components when
preparing for medical surge
In June 2008, we reported that even though States had made efforts
to increase hospital capacity, provide care at alternate care sites,
identify and use medical volunteers, and develop appropriate altered
standards of care, they expressed concerns related to all four of these
key components of medical surge.
Hospital capacity concerns. We reported that State officials raised
several concerns related to their ability to increase hospital
capacity, including maintaining adequate staffing levels during mass
casualty events, a problem that was more acute in rural communities.
While 19 of 20 States we surveyed reported that they could increase
numbers of hospital beds in a mass casualty event,\29\ some State
officials were concerned about staffing these beds because of current
shortages in medical professionals, including nurses and physicians.
Some State officials reported that their States faced problems in
increasing hospital capacity because many of their rural areas had no
hospital or small numbers of medical providers. For example, officials
from a largely rural State reported that in many of the State's
medically underserved areas hospitals currently have vacant beds
because they cannot hire medical professionals to staff them.
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\29\ Officials from the remaining State reported that they did not
know how many beds were available State-wide above the current daily
staffed bed capacity.
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Alternate care site concerns. Some State officials reported that it
was difficult to identify appropriate fixed facilities for alternate
care sites. Officials from two States reported that some small, rural
communities had few facilities that would be large enough to house an
alternate care site. Officials from some States also reported that some
of the facilities that could be used as alternate care sites had
already been allocated for other emergency uses, such as emergency
shelters. Some State officials also reported concerns about
reimbursement for medical services provided at alternate care sites,
which are not accredited health care facilities, and concerns regarding
how certain Federal laws and regulations that relate to medical care
would apply during a mass casualty event for care provided at
alternative care sites.
Electronic medical volunteer registry concerns. We reported that
some States reported that medical volunteers might be reluctant to join
a State electronic medical volunteer registry if it is used to create a
National medical volunteer registry. PAHPA requires ASPR to use the
State-based registries to create a National database. According to
State officials, some volunteers do not want to be part of a National
database because they are concerned that they might be required to
provide services outside their own State. Officials from one State
reported that since PAHPA was enacted, recruiting of medical volunteers
was more difficult and that the Federal Government should clarify
whether National deployment is a possibility. ASPR officials said that
they would not deploy medical volunteers nationally without working
through the States. Additionally, some States expressed concerns about
coordination among programs that recruit medical volunteers for
emergency response. Officials from one State reported that Federal
volunteer registration requirements for the Medical Reserve Corps (MRC)
\30\ and the electronic medical volunteer registry programs had not
been coordinated, resulting in duplication of effort for volunteers.
Officials from a second State reported that a volunteer for one program
that recruits medical volunteers is often a potential volunteer for
another such program, which could result in volunteers being double-
counted. This may cause staffing problems in the event of an emergency
when more than one volunteer program is activated.
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\30\ MRC is a Federal program within the U.S. Surgeon General's
Office, which is in HHS. MRC units are community-based and organize and
utilize volunteers to, among other things, prepare for, and respond to
emergencies. MRC volunteers include medical and public health
professionals as well as other community members, such as interpreters
and legal advisers.
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Altered standards of care concerns. Some State officials reported
that they had not begun work on altered standards of care guidelines,
or had not completed drafting guidelines, because of the difficulty of
addressing the medical, ethical, and legal issues involved. For
example, in 2005 HHS estimated that in a severe influenza pandemic
almost 10 million people would require hospitalization,\31\ which would
exceed the current capacity of U.S. hospitals and necessitate difficult
choices regarding rationing of resources.\32\ HHS also estimated that
almost 1.5 million of these people would require care in an intensive
care unit and about 740,000 people would require mechanical
ventilation. Even with additional stockpiles of ventilators, there
would likely not be a sufficient supply to meet the need. Since some
patients could not be put on ventilators, and others would be removed
from ventilators, standards of care would have to be altered and
providers would need to determine which patients would receive them. In
addition, some State officials reported that medical volunteers are
concerned about liability issues in a mass casualty event.
Specifically, State officials reported that hospitals and medical
providers might be reluctant to provide care during a mass casualty
event, when resources would be scarce and not all patients would be
able to receive care consistent with established standards. According
to these officials, these providers could be subject to liability if
decisions they made about altering standards of care resulted in
negative outcomes. For example, allowing staff to work outside the
scope of their practice, such as allowing nurses to diagnose and write
medical orders, could place these individuals at risk of liability.
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\31\ By comparison, seasonal influenza in the United States
generally results in 200,000 hospitalizations annually.
\32\ Department of Health and Human Services, HHS Pandemic
Influenza Plan (Washington, DC, November 2005).
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While some States reported using AHRQ's Mass Medical Care with
Scarce Resources: A Community Planning Guide to assist them as they
developed altered standards of care guidelines, some States also
reported that they needed additional assistance. States said that to
develop altered standards of care guidelines they must conduct
activities such as collecting and reviewing published guidance and
convening experts to discuss how to address the medical, ethical, and
legal issues that could arise during a mass casualty event. Four States
reported that, when developing their own guidelines on the allocation
of ventilators, they were using guidance from another State, which had
estimated that a severe influenza pandemic would require nearly nine
times the State's current capacity for intensive care beds and almost
three times its current ventilator capacity, requiring the State to
address the rationing of ventilators. In March 2006 the State convened
a work group to consider clinical and ethical issues in the allocation
of mechanical ventilators in an influenza pandemic.\33\ The State
issued guidelines on the rationing of ventilators that include both a
process and an evaluation tool to determine which patients should
receive mechanical ventilation. The guidelines note that the
application of this process and evaluation tool could result in
withdrawing a ventilator from one patient to give it to another who is
more likely to survive--a scenario that does not explicitly exist under
established standards of care. Additionally, some States suggested that
the Federal Government could help their efforts in several ways, such
as by convening medical, public health, and legal experts to address
the complex issues associated with allocating scarce resources during a
mass casualty event, or by developing demonstration projects to reveal
best practices employed by the various States.
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\33\ The group brought together experts in law, medicine, policy
making, and ethics with representatives from medical facilities and
city, county, and State government.
---------------------------------------------------------------------------
In May 2008, the Task Force for Mass Critical Care, consisting of
medical experts from both the public and the private sectors, provided
guidelines for allocating scarce critical care resources in a mass
casualty event that have the potential to assist States in drafting
their own guidelines. The task force's guidelines, which were published
in a medical journal,\34\ provide a process for triaging patients that
includes three components--inclusion criteria, exclusion criteria, and
prioritization of care. The exclusion criteria include patients with a
high risk of death, little likelihood of long-term survival, and a
corresponding low likelihood of benefit from critical care resources.
When patients meet the exclusion criteria, critical care resources may
be reallocated to patients more likely to survive.
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\34\ The task force included officials from DHS, HHS, ASPR, CDC,
DOD, and VA. See Asha V. Devereaux et al., ``Definitive Care for the
Critically Ill During a Disaster: A Framework for Allocation of Scarce
Resources in Mass Critical Care: From a Task Force for Mass Critical
Care Summit Meeting, January 26 to 27, 2007, Chicago, Il.,'' Chest
(2008): 133, 51-66.
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concluding observations
In our June 2008 report, we noted that though States had begun
planning for medical surge in a mass casualty event, only 3 of the 20
States in our review had developed and adopted guidelines for using
altered standards of care. HHS has provided broad guidance that
establishes a framework and principles for States to use when
developing their specific guidelines for altered standards of care.
However, because of the difficulty in addressing the related medical,
ethical, and legal issues, many States were only beginning to develop
such guidelines for use when there are not enough resources, such as
ventilators, to care for all affected patients. In a mass casualty
event, such guidelines would be a critical resource for medical
providers who may have to make repeated life-or-death decisions about
which patients get or lose access to these resources--decisions that
are not typically made in routine circumstances. Additionally, these
guidelines could help address medical providers' concerns about ethics
and liability that may ensue when negative outcomes are associated with
their decisions. In its role of assisting States' efforts to plan for
medical surge, HHS has not collected altered standards of care
guidelines that some States and medical experts have developed and made
them available to other States. Once a mass casualty event occurs,
difficult choices will have to be made, and the more fully the issues
raised by such choices are discussed prior to making them, the greater
the potential for the choices to be ethically sound and generally
accepted.
Mr. Chairman, this concludes my prepared statement. I would be
happy to answer any questions you or other Members of the subcommittee
may have.
Mr. Carney. Thank you for your testimony, and I would like
to thank each of the witnesses for their testimony. We will now
go to the questions. Mr. Bilirakis and I will ask questions for
5 minutes each to the panel alternating back and forth, and we
will take as long as it takes. I will start, this question is
for Dr. Jolly and Dr. Pane both. How do you see, and I know you
mentioned this in your opening statements, but how do you see
DHS and HHS working together in practical terms, something
beyond the National Response Framework? I know how it is
supposed to work on paper but in practical terms, how do you
see it?
Dr. Jolly. I will start on a very practical level. Part of
this is driven really by the day-to-day workings between the
department, between the part of DHS, the operations director at
FEMA, and parts of HHS, ASPR, CDC and other parts that really
work through issues on a day-to-day basis that have not risen
to crisis levels or result in planning or preparedness or
exercises. For large-scale events, it is well recognized that
well worked out that DHS is the lead for overall management and
the health and medical aspects are led by HHS, but they are
obviously interplayed among those that we facilitate. It is
hard to work out all the details of that over time, but as we
work more and more on this it gets smoother during incidents,
and I think each one of these teaches us what is going to
happen on the next one. Dr. Pane.
Dr. Pane. Let me just add, Mr. Chairman, that I couldn't
agree more with what Dr. Jolly is saying. Having been an ER doc
myself for a lot of years and a hospital executive and State
health department director who got these grants, I think one of
the most important things we can do in Washington is to walk
the talk. We ask our wardees to coordinate and drill and work
together, and I think we need to do the same thing, so it is
very important that we do that. We have a lot of activities
going on with the DHS, as well as within our own department in
CDC trying to be sure we are coordinated and working through
issues proactively. There is regular contact, as Dr. Jolly
alluded to, because the Office of Health Affairs and various
parts of HHS on a host of things.
Certainly in times of response as I allude to in my
testimony we are in the command centers together working very
closely with our regional and emergency coordinators, with
Homeland Security officials in the State, as well as in the
National center during a disaster. In addition, we have a
working group that we are part of that is working to coordinate
grant guidance and others things, so we have a group that is
looking at the MRS system, looking at UASI dollars, looks at
the CDC TEF dollars, looks at our SUP dollars, and tries to
take a look at are we doing a coordinated grant notice,
coordinated metrics, is it appearing to States that we are
walking the talk.
I know when I got those dollars, that is how I acted with
them. I am glad to get them from various parts of the Federal
Government, but it is your job at the State level or local
level to make music in the orchestra. We are giving you
sections. You need to make the music here locally. So it is
very important. It is a job that is too important not to
succeed in, so we take great pride in trying to work through
some of those issues and make a more coordinated Government so
we have a more effective response locally.
Mr. Carney. What is the nature of your relationship beyond
the National response plan? You talk about daily contacts.
Characterize that, please.
Dr. Jolly. With or without a document called the National
Response Framework, which is obviously a very important
document, on a daily basis we have, for instance, planning
groups on anthrax response, on H1N1 response. Well before the
beginning of this pandemic on a regular basis the interagency
meetings among DHS, HHS, and all our other interagency partners
happened on a very regular basis to plan for the various
contingencies of a pandemic, and then on specific issues such
as vaccine distribution or countermeasure distribution, or
surveillance, different parts and different subject matter
experts. The people on the ground who really know the most
about these specific issues get together sometimes daily,
sometimes weekly, go to meetings together, and not just for the
sake of meetings but to really see how the assets that the DHS
has and the assets that HHS has, and, most importantly, the
assets that State and local officials have that are partially
funded by the Federal Government and locally funded can work
together.
Mr. Carney. Ms. Bascetta, both DHS and HHS have surge
responsibilities. How are they doing from GAO's perspective in
coordinating those?
Ms. Bascetta. This is a subject that we are still looking
at, and specifically we have on-going work on lessons learned
from the recent--the most recent response to the first two
waves of the pandemic. We noted in our work on pan flu that
clarification of the rules and relationships between those two
departments in particular but also other Federal agencies and
components within HHS is important to continue to work on and
to refine. I have a couple of experiences with DHS and HHS in
other work that I conducted. One was on the case of the
tuberculosis traveler who boarded a plane and went overseas.
There was actually a very successful story as result of that
where CDC and Customs and Border Patrol Control with DHS kind
of had a rocky start working together originally because they
came at the problem from very diverse points of view.
But they learned a tremendous amount through that
experience, and I think it is that daily interaction, person to
person, certainly not at the higher levels, that is important
in forming the kinds of relationships we need to have
successful response.
Mr. Carney. I will explore that in my next question, but
now Mr. Bilirakis for 5 minutes.
Mr. Bilirakis. Thank you, Mr. Chairman. The first question
is for Dr. Jolly. Is the medical community prepared if disaster
or terrorism strikes as the title of this hearing offers, and
also is the medical community capable of handling a
bioterrorism attack such as anthrax or smallpox while
concurrently responding to a pandemic? Won't the same resources
that are currently stretched thin face even greater strain, and
what needs to be done to make our preparedness better and how
are we identifying existing gaps and capabilities and who is
charged with correcting them?
Dr. Jolly. That is a very comprehensive question.
Hopefully, I can provide a very comprehensive answer. The
medical community is a very broad community, and it is not just
the emergency medical community or critical care community, but
the broad medical community, including nursing, physician
assistants, administrators, the public health community. You
know, there are many, many large challenges that we could
potentially face. I think the medical community still has work
to do. There is still educational work. There is still training
work. There is still planning and exercise work that the
community needs to do to surge beyond the day-to-day hard work
it is doing right now. These are not a group of people who are
sitting still waiting for the next thing to happen.
We are prepared in the mist of a pandemic were other things
to happen. Our preparation continues for those. Our
preparedness continues for those. Any concurrent hazards would
be a challenge but those are things we think about. We never
think about just doing one thing at a time. As we work through
this, I think there are many things to work on, both
coordination, which sounds a bit like a bureaucratic term, but
it has real meaning, getting emergency preparedness, law
enforcement, other critical infrastructures, together with the
medical community to really broaden the definition of what
health care surge really is beyond just the four walls of one
or more hospitals.
There is much more we can work on with you, and I think the
models of the prior MMRS program, over 110 in the country,
serve to model some of those workings locally, and I think we
can broaden that Federally.
Mr. Bilirakis. Would you like to add something, sir?
Dr. Pane. Just briefly, I would add that as Dr. Jolly has
said this is a complicated thing, and what we have tried to do
over the years, and I have seen it myself as an ER doctors, and
I am sure Til has as well, I think it has never been better but
we still have a ways to go. I mean we have come a long, long
way thanks to your support in Congress. Some of these dollars
we have been able to put out to States, we really, I think,
improved coordination and guidance. But the real action, I
believe, is with State and localities and hospitals, docs,
other health professionals, and also working with the emergency
management community, police, fire, and others. A lot of that
has happened through various trainings and exercises, which I
think is the key.
We contract for a couple of studies with the University of
Pittsburgh Medical Center, the Center for Security, and they
have looked at both our programs, and I think what they have
said is the best thing that we have done and we should keep
doing is getting people to work together, talk together, drill,
exercise, training, increase that comfort level as the GAO
said. That is, I think, key in disasters. Being able to respond
to any hazard is having that experience of walking though the
problem and actually taking real-life exercises, doing after-
action report, what happened, what we can do better. A lot of
that goes on, and I think we are making tremendous headway, but
we certainly have a way to go, sir.
Mr. Bilirakis. Anyone else that would like to respond to
that?
Ms. Bascetta. I will just add two things. One very concrete
thing is that our vaccine technology is very antiquated. We
still have egg-based production and we really need to move
forward on what is happening to develop cell-based technology
so we can get vaccines produced much more quickly. The second
thing is that the question is always how well are we prepared
and prepared for what. We are always well prepared for what
just happened, but it is hard to anticipate what is coming down
the pike. As the Chairman said in his opening remarks,
balancing the costs and benefits of that preparation is really
a tough nut to crack. I would like to think about also building
in resilience. You want to make the assumption that things are
going to happen but they are, and figuring out the flexible
ways to be resilient and to respond with minimizing the
disaster is an important framework to begin focusing on.
Mr. Bilirakis. Thank you. Dr. Jolly, given that the
hospital preparedness is a local issue and that the Federal
Government support this effort is provided by the Department of
Health and Human Services, what role does the Office of Medical
Readiness play in ensuring that hospitals are able to increase
their surge capacity?
Dr. Jolly. As you said, the primary funding and support for
hospital preparedness resides within Health and Human Services,
and they do quite a good job at that. As you know, FEMA has a
number of grant and training programs, some of which are
applicable simply to health care systems and more which are
more broadly applicable across communities. One of the
important roles of our office is to look at those grant
functions to work with FEMA and to look at them from a health
perspective. Our office is working with offices with ASPR, the
Assistant Secretary for Preparedness Response, to try to
coordinate some of those grant time lines, some of the
guidance, and try to make sure that the FEMA grant programs
consider health aspects of what they are doing and tie better
so that local officials, as Dr. Pane used to be, can make some
sense out of the various pools of money that are coming to
them.
Mr. Bilirakis. Thank you. Thank you, Mr. Chairman.
Mr. Carney. Okay. Ms. Bascetta, let us return to the line
of questions from before. How is the coordination going? You
were talking about the tuberculosis case. We seem to learn
going forward after an event happens how to respond. Is that
the best model?
Ms. Bascetta. No, it certainly isn't but the reality is
that 9/11 is still a relatively recent event, and we have
learned a lot from it and from Katrina and from pan flu, and
overcoming the silos within departments and across departments
is something that really requires practice. I think we have
learned the lesson of practice, as Mr. Pane said. Many experts
who have studied disaster response have pointed out that
getting to know each other on the day of the response isn't
going to work, and I think the lesson of exercising is pretty
clear.
Mr. Carney. This is for everybody here, including Ms.
Fitzgerald. We are going to get to you, don't worry. When
talking about exercising--as somebody who has been in the
military for a lot of years now, we exercise a lot of different
scenarios, a lot of different things. We do it all the time
when we train. How often do you exercise? Is the exercise
adequate? Is it reflective of reality? Those are the things
that we are really concerned with. So, Dr. Jolly, why don't you
start and we will just work down the table?
Dr. Jolly. I think that exercising just for exercising's
sake is not a good idea. I think we are increasing our number
of exercises. FEMA, the National Exercise Division within FEMA
maintains the Homeland Security Exercise and Evaluation
Program, which is an interagency effort to coordinate those
exercises. I think as we move toward more realistic exercises,
it is important to exercise sometimes to a point of failure in
the exercise and to have the leaders that are in those
exercises go through very difficult rather than scripted I know
what I am going to do situations. I think the leadership of the
National Exercise Division is thinking about--is moving in that
direction as all of us in Government from principals, the
Cabinet members, down through the operators in the departments.
Dr. Pane. The training aspect and exercise is the core of
the Hospital Preparedness Program, and we are looking for
hospitals to actually work together. This is the Hospital
Disaster Plan we are talking about. This is actually groups of
hospitals or health facilities in a region along with other
professionals in the larger emergency management community
working together. We have specific exercise requirements, and a
lot of us are geared toward that regional concept as well as
State-wide activities in the larger emergency management
community with DHS and FEMA. There is a lessons-learned entity
through DHS called LLIS, Lessons Learned Information System, I
believe, which we upload all these things, and we are trying to
single out the health part of that and make it more easy to use
and get that word out because it is probably the primary thing
we can do.
Those of you who watched the game last night in watching
the defense, we do an all-hazards approach because we want to
be ready for anything offense throws at us whether it is a
chem, a bomb, pan flu, so that the core things of drilling and
exercising together, the training aspects, the communication
system, calling up volunteers, some of the same principles
would be used for many things. We try to emphasize that and
keep pushing it to get better to perform its metrics and work
groups, NIMS requirements, the National Information Management
System, we work with hospitals to enhance that. So a lot of
that activity is going into exercises and making it better to
get a better yield.
Ms. Fitzgerald. There are so many opportunities for
exercising across the State of Pennsylvania, both at the
individual hospital level, at a county and municipal level,
engaging the county and municipal emergency management engaging
at a regional level and then obviously engaging at the State-
wide level. From a State health department perspective on a
regular basis we are encouraging communications exercising so
we are testing our 800 megahertz radio system. We are testing
our ability to feed data into our facility's database so that
we are prepared for something like the H1N1 event.
We test our equipment so we purchase the portable
hospitals. It is not rocket science to put up one of the
portable hospitals but on a regular basis we need to pull them
out and make sure that everything is still working, so we are
exercising that. Ultimately, there are so many pieces of our
all-hazards plan that need to be trained to an exercise that
this is an on-going effort year after year after year to
continue to work at the individual hospital level as well as at
the regional level.
Mr. Carney. What is your relationship with the Federal
Government when you do these exercises?
Ms. Fitzgerald. We absolutely report our exercises to the
Federal Government.
Mr. Carney. Do they participate? Is there any
participation?
Ms. Fitzgerald. Absolutely. They are always willing to come
in and participate in our exercises, so at least once a year we
probably have Federal representation at one of our exercises.
Mr. Carney. Okay. We will get back to you. It is Mr.
Bilirakis' turn.
Mr. Bilirakis. Thank you, Mr. Chairman. This is for Dr.
Jolly. The MMRS program supports the integration of emergency
management, health, and medical systems into a coordinated
response to mass casualty incidents caused by any hazard
including pandemic influenza. Successful MMRS grantees reduced
the consequences of a mass casualty incident during the initial
period of response by having augmented existing local
operational response systems before the incident occurs. How
are we utilizing the MMRS system to respond to shortages in
vaccine and personal protective equipment such as the N95
respirator masks?
Dr. Jolly. Well, the MMRS system, as you know, has a long
history of coordinated functions among the various services
within a community. Over 100 communities are MMRS cities and
work law enforcement, fire, EMS, and hospitals to create a
coordinated local and then regional function. The specific
shortages or potential shortfalls in some of the PPE and some
of the pharmaceuticals are not really a function of the MMRS,
but they are important in analyzing the needs for those and
also sometimes in distributing. At least one of our MMRS
jurisdictions asked to help with a local community vaccine
distribution which they had expertise in Maine, I believe it
was, to provide the services that a local college couldn't
provide but they had people who needed a vaccine, so they do
serve as a resource to provide those services when they are
needed and then be prepared when large things happen.
Mr. Bilirakis. Thank you. Dr. Pane, approximately 800,000
doses of H1N1 vaccine were recalled last month. Most of these
doses were used in young children ages 6 months through 3 years
old. The reason for the recall was that tests show that the
vaccine might not have been potent enough to protect against
the virus. What caused this failure and how has it been
corrected? Doesn't this error further strain existing medical
surge capacity resources, and are we doing enough to protect
our Nation's children, and all high-risk groups for that
matter?
Dr. Pane. I will have to get back to you on some of the
details of that through our BARDA, Biomedical Advance Research
and Development Authority, part of HHS and part of ASPR, that
is really dealing with countermeasure development. I can tell
you, Mr. Bilirakis, as Cynthia Bascetta mentioned, we are still
dealing in a primary world of non-manufacturers, and we are
still in an egg-based as opposed to cell-based technology. I
know BARDA, a lot of their work has been geared toward
expanding through contracts and incentives the manufacturing
base to get more vaccine today and the, second, to move toward
cell-based.
In terms of H1N1, I think everybody in the room has
probably read about the development was slowed. It didn't grow
as fast. All viruses are a little different. While I think it
turned out to be safe and effective and it is still being
promoted--in fact, I was sitting, I think, in the hotel last
night, and I saw a Pennsylvania about H1N1, to go get it, so we
really work closely with State and local public health to
recommend the use of that. I think the overwhelming evidence is
the vaccine is safe. Certainly, this time around, I think
without BARDA and the work HHS has done, it would have been
even slower getting out. We always assume that something like
this would happen overseas. We have had months to get ready and
this happened in our back yard and we had to develop things
rapidly, so I think all said and done the vaccine was gotten
out as quickly as we could, and lucked out this wasn't a real
serious virus.
But your point is well taken. We need to improve our
ability to manufacture vaccines quickly and safely get them
out. The safety among children is key. In fact, we are dealing
right now with--there is a commission on children disasters
that have issued a number of recommendations that we are trying
to incorporate into our guidance and other means, and certainly
vaccine is one of them. So I think your question is timely and
accurate and it is very important to the public that vaccines
are safe and timely. I know as a father and as a local public
health official myself that that was one of the key things that
you want to pay a lot of attention to and do your best to
advocate and I think our States are doing a good job with it
and we need to continue that.
Mr. Bilirakis. Thank you. Why don't I wait till the next
round, Mr. Chairman?
Mr. Carney. Dr. Pane, just in the last round of questions
the LLIS was mentioned. Does HHS actually use the LLIS, the
Lessons Learned Information System?
Dr. Pane. We do, and I think we have agreed that this is
the vehicle we want to use, and so we are going to work even
harder to encourage hospitals to get this information put in
and then to have a health section because it comes in all kinds
of preparedness and disaster exercises, so it would be most
helpful for health and medical. We are going to continue to
promote that, so, yes, we believe we can use it. We also, of
course, have other means of gathering best practices and having
dialogue with our States, and I won't go into that now because
I know your time is limited. But when I arrived, best practices
identification and innovation was something I think we could do
a better job of finding them, working with our States to
recognize them, and promoting their adoption faster because
there is great work going on, as we have seen here today, and
we need to be sure those lessons learned when something goes
wrong, but also when something needs happening or something
innovative is happening around the country for a problem, we
want others to know about it.
Mr. Carney. Okay. I want to shift gears just a little bit
now and talk about the altered standards of care crisis,
whatever you want to call it, from all your perspectives. How
do we address this, Dr. Jolly and Dr. Pane, in terms of medical
surge? What are your perspectives on this?
Dr. Jolly. I would acknowledge what our colleagues from GAO
have found, and these are difficult issues. This is more as a
position as a Homeland Security official to think that there
are somewhat different standards or crisis standards in a
large-scale incident than on a day-to-day basis are difficult
things to work through legally and morally and ethically and
practically. This is the sort of thing you do train for and
think about. You think about what is going to happen if I have
to take care of 20 people at once and I don't have enough to do
it or 100 people or 1,000 people at once, and I don't have
enough people to do it. I think that we need to consider these
issues and think through them. This is something we are happy
to support, support HHS, which was clearly in these sorts of
situations. The greater community, the greater society has a
role to play and I think in practical terms were one of these
things to be carried out.
Our department, HHS, and many others would be involved in
some of the decision-making and the communications of this
because there is also an issue of having the public understand
what we all are facing and being open and honest with the
public.
Dr. Pane. All our work at HHS, basically the raison d'etre,
if you will, is geared toward helping the health system meet
surge capacity and deliver the best quality care no matter what
hits us and no matter how much. Our guidance is really geared
towards hospitals and states optimizing the use of resources
whether it is the community, the docs in the community,
clinics, primary care sites, alternative sites of care to being
able to call up medical volunteers, share ventilators, work
together to share resources to take on whatever hits us and
keep the standard of care high. That said, for standards of
care, and we did agree with Ms. Bascetta' report that the GAO
report was excellent. It is an important issue.
It is also important to note detailed standards of care are
happening locally. The Federal Government does not set
standards of care, but we can do guidance and best practices,
and I think we need to do more in this area. One thing that HHS
has done is contracted, as was mentioned, with the Institute of
Medicine, an esteemed group, and they issued or are issuing or
finalizing some guidance in alternative standards of care.
There is going to be a second part of that report. I know, as
was mentioned, the Agency of Healthcare Research and Quality
was contracted for and they issued a guide. I think some States
have used that.
We are also trying to collect lessons-learned or
innovations that I mentioned earlier in this area. Some States
are ahead of others in fatality management planning or
alternative standards and we want to capture those, so a lot of
activities there. But I just wanted to emphasize our goal is to
deliver the top notch and best care we can under any scenario
and expand to do it. Alternative standards of care is one
aspect of that, and we are going giving it more attention.
Mr. Carney. Ms. Fitzgerald, please.
Ms. Fitzgerald. From a State health department perspective,
we see our goal as taking the Federal guidance as well as some
of the other best practices that the States have started to
develop and make sure that our health care partners across the
State are aware of these materials and that we hold forums to
have discussions prior to an emergency so that we can better be
on the same page during the emergency because these discussions
are tricky and involve a variety of professionals that need to
come to the table. So in developing this guidance document that
is almost ready to be released, it will initiate a lot of great
conversations across the State so that health care
professionals and emphasis can be more on the same page prior
to the emergency and, therefore, be better ready to respond and
take care of the patients during an emergency.
Mr. Carney. From your perspective, should the altered care
plan come from the States upward or from the Federal Government
downward? Should each State have its own standard, should each
locality have its own standard or should it be----
Ms. Fitzgerald. Well, I think one of the challenges when
you talk about standards of care is that in the end is it
becomes a very individualized patient-physician decision at the
bed side, and so I think when you are talking about standards
of care you are really needing to talk about modified health
care delivery based on certain circumstances, and so I think
the guidance that the Federal Government and the State
governments can put out to identify possible scenarios and
possible responses to the scenarios is the best thing we can do
to provide support to the individual physician at the bedside.
Mr. Carney. Ms. Bascetta, please.
Ms. Bascetta. Thank you. From our perspective, as you have
heard, once an event occurs there are going to be very
difficult choices that need to be made. The best example is
what would have happened in pan flu if it had been much more
virulent and we had needed to take people off of respirators,
decide, you know, who was going--decide how has the best chance
of survival and will get care is essentially what we are
talking about, something we are not used to in this country. So
we don't think that it is the Federal Government's
responsibility to set those standards, but it does play an
important role in providing guidance. We seen this IOM report,
which we haven't fully evaluated it but we see it as a very
important step in providing that general guidance to the
States, but we do think that there needs to be a heavy local
component.
The most important thing is to remember that as fully and
as transparently we can discuss these issues above-board before
an event then the greater the potential is that the choices
that we will be making will be ethically sound, and, more
important, generally accepted by the public.
Mr. Carney. Thank you. We will explore that again. Mr.
Bilirakis.
Mr. Bilirakis. Thank you, Mr. Chairman. Ms. Fitzgerald, in
the event of an emergency in surrounding States like New York
and New Jersey, Pennsylvania might experience an influx of
patients and evacuees. Are Pennsylvania's hospitals prepared to
receive these patients if need arises?
Ms. Fitzgerald. Hospitals have spent the last many years
considering surge options and developing plans to manage surge.
I think that hospitals will have an easier time managing surge
from another area than when the entire State might be affected
through a pandemic, for example. We know that hospitals are
extremely busy every day and don't have a lot of immediate
resources for surge, but I think hospitals have done a lot of
planning to plan for surge. In addition, we have a lot of
resources throughout the State that can be brought in to assist
with the hospital or patients could be dispersed throughout the
State. So while I think there is always more planning and
training and exercising that we need to do, I think hospitals
have done a lot of great work to prepare for a surge.
Mr. Bilirakis. How does Pennsylvania handle issues
surrounding the credentialing medical personnel that may wish
to volunteer during a disaster or terrorist attack? What issues
might medical professionals from outside the Commonwealth face
in trying to volunteer in Pennsylvania? Last, what issues may
medical professionals from Pennsylvania face in trying to
volunteer in other States?
Ms. Fitzgerald. Pennsylvania has developed the Statewide
Emergency Registry for Volunteers in Pennsylvania called
SERVPA. It is a database that connects directly to our
Department of Licensure so that we are able to verify medical
licenses and nursing licenses when people register in our
system and we are able to verify that as we to deploy a
volunteer. So we are able to easily verify people who volunteer
within the State. As far as sending volunteers to other States,
obviously we can share our credentialed volunteer's information
with other States if they are deployed to other States.
As far as allowing volunteers to work in Pennsylvania, that
is an agreement we would have to have with another State. So I
think we have done a lot of planning around this issue but I
think there is additional planning we can do to make sure it
would be a smooth transition to allow people from other States
to work in Pennsylvania.
Mr. Bilirakis. Thank you. I yield back, Mr. Chairman.
Mr. Carney. Thank you, Mr. Bilirakis. On the crisis
standards of care issue, Dr. Pane, what is HHS' recommendation
on the standard? You haven't signed on necessarily to a more
National element. Do you have a thought on this?
Dr. Pane. Yeah, I think the whole concept of alternative
standards of care, crisis standards of care, it is an important
issue and we are trying to take that on. The States and others
have raised that, GAO. It is certainly part of what you do in a
disaster. You need to consider all your options and standards
of care. Should you be overwhelmed is certainly one of them. So
to put a little more meat on the bones there and get more
enlightened guidance, I think both based on the current science
and also what the consensus is was mentioned, a practitioner--
as you know, in Government, and I feel as a local health
director, I could only do what the public believed in and
supported.
So in order to do that, you really have to get the science
thing down but you have to get the concepts that are accepted
by a large majority of people and health professionals, so I
think that is what the IOM, HHS contracting with them to bring
together that kind of a group of experts to move that ball down
the field, and there will be more to say about that, and also
the AHRQ project. But, again, as was mentioned, this is a local
issue. Standards of care and the nuances are set. Even
vaccines, CDC issues a list of priorities but in H1N1 States
had to make decisions between the lines, and this happens all
the time. So we rely on our States and local professionals to
make the hard, tight, close decisions, but certainly from the
Federal side we can draw experts and come up with guidance and
some of the principles, things that work that will enable that
process and make it better.
Mr. Carney. Ms. Fitzgerald, I had a question in terms of
just a numbers question. What is the surge capacity for the
mobile hospitals for the State now, do you know? How many beds
can we bring to bear if need be?
Ms. Fitzgerald. Yes. Each of the eight portable hospitals
has 50 beds that can take care of up to seven patients a day,
so they can each take of care up to about 350 patients a week,
and so it brings significant surge capacity that is also mobile
so that we can move it where I believe we need to in the State.
In addition, the 19 medical surge trailers also have 50 beds in
each of the trailers. The difference is the medical surge
trailers don't come with their house basically, and you would
set up the medical surge trailers in a fixed facility such as a
gymnasium.
Mr. Carney. We had the pleasure this morning of visiting
Geisinger and looking at sort of the remote care that they--the
I system--that they have to help remotely care for patients. Do
you see that coming on-line or do you see any hope for that in
terms of surge capacity?
Ms. Fitzgerald. I had seen that system I guess today for
the first time so I haven't, I apologize, thought a lot about
that system, but I was----
Mr. Carney. You can kind of free associate here, if you
like, from your position.
Ms. Fitzgerald. I was really impressed with that system and
I think it looks like there is a lot of opportunity for being
able to expand the number of patients that can be cared for.
Mr. Carney. That was my impression as well, but hearing it
from the professionals would be great. Ms. Bascetta, in your
estimation from the GAO's perspective, what are the top two or
three challenges that you see in terms of preparedness and
surge capacity and that sort of thing, and how do we address
them?
Ms. Bascetta. One is related to the decline in the economy
that we are experiencing. Public health departments have been
chasing the same kinds of budget cuts that other State
functions face so that is a matter of funding, and it is all
dollars. The places that are particularly hidden as situations
are surveillance and finding clinical access to especially low-
income, low-income people. We have talked a lot about crisis
standards of care, and we see progress being made in an area.
We would like to be able to see States take advantage of the
IOM report and the Federal clearinghouse if and when it is
actually put on-line to get some things down on paper ahead of
disasters, and continuing to learn from experiences like
Katrina and pan flu in particular is a very, I think, fruitful
area for us to continue pursuing.
Mr. Carney. Given the scarce resources that you just
mentioned, where would you focus those scarce resources right
now to get the most bang for the buck?
Ms. Bascetta. That is a good question. I think that the
all-hazard perspective and making sure that there are a lot of
things where dual use is really important, making sure that
surveillance isn't compromised, that there is basic public
health access functions for the low-income populations where
people with chronic conditions are not compromised so that you
are faced with a disaster. You have got an ability to do the
kind of triage that you need in the local area continuing to
shore up the basic public health functions. I think that is
important because that is the piece that needs to interact with
law enforcement and other responders.
Mr. Bilirakis. Thank you. Dr. Jolly, are the incident
management assistant teams that Secretary Napolitano spoke of
assisting the MMRS system and providing effective support at
the local response, and is HHS supporting the MMRS system with
supplies from the National strategic stockpile?
Dr. Jolly. Well, in response, there is a complex group of
response elements that would all come into play. Incident
management assistant teams are part of the FEMA response
framework. We support that. Other departments support that. To
take Federal leadership into a region and they go on the ground
in various crises, including one that is on the ground in Haiti
now to assist with that part of the Federal response, the MMRI
systems work within the State and the local level and our local
resources that are designed to build up the response
immediately before those IMATs can get there. The strategic
nationals stockpile, should it be needed, is a CDC asset and
assets from that either medical countermeasure or PPE medical
equipment, other things that are in the S&S be needed, those
would quickly be lost and brought into a State and then
distributed in accordance with State guidelines for how those
things get distributed. So it is essentially a response web for
how those things get distributed, so it is essentially a
response web that all works together, starting at the local
level at the most basic level of response and building up to
include the various Federal assets that are there.
Mr. Bilirakis. Thank you. Dr. Pane, is there a shortage of
N95 respirator masks in the health care setting, and what is
driving that shortage, if one exists? Is it cost, product
capability and/or allocation? Where is the perceived bottleneck
occurring and is there enough vaccine available to not only
health care workers but law enforcement in a timely manner to
ensure that personnel protection if there is personal
protection if there is any shortage of N95 respirator masks for
them?--so a concern about the protection, yes.
Dr. Pane. Congressman, I may need to get back to you on
some of the details on this. The CDC is really the lead on
this, but it definitely is an area that was recognized and is
being looked at by them. On the N95 masks, I know the big issue
that was discussed, and I think my colleagues were on these
calls as well, had to do with when do you use N95, who needs it
and when versus a more simple mask which are readily available.
I think a supply of ventilator, N95 masks, and regular masks is
important. The main issue, and I think CDC is working on this,
I don't know if there was a final conclusion, there was some
difference between what the OSHA standards were regarding N95
masks and perhaps the response standards, so the only issue--
there is enough depending on what the criteria is. If the
criteria move a little, there may be a shortage. So I think the
CDC--we will have to get back to you on if there is final
guidance or where they stand in that process but it all came
down to when is it appropriate clinically to use a regular
mask. I think it is prolonged periods of intense contact with
folks who are infected you would use an N95 versus a regular
mask, so that is the status of that as far as I can tell right
now.
Mr. Bilirakis. Thank you, sir. Thank you, Mr. Chairman. I
yield back.
Mr. Carney. Thank you. We will close this panel of the
hearing on this, my last couple of questions. Dr. Pane, since
funding for hospital preparedness programs, hospital
preparedness programs is, I think we would all agree, not as
great as it should be. How concerned are you that States and
Tribal entities and localities have what they need? Will they
be able to build and maintain a medical surge capacity? What
impediments are we facing here? Is there a formula for funding
you think each hospital should have? Is there some way that we
can adequately assess where we are in terms of being able to
address and respond to any kind of need, be it natural or man-
made?
Dr. Pane. Mr. Chairman, I share your thoughts and concerns
on that. We know, as I mentioned earlier, the States, the
incredible stress they are under now with the economics and
other issues, and we try to be responsive to them. In our
guidance, we made it a 3-year planning cycle rather than a 1-
year, which was brought up. We made it a July-to-July budget
cycle, which is no easy matter for HHS, but we did get that
through to try and make it better and stretch those dollars
further. It is a formula-based program. Essentially its
population is how you get your share, and then at the State
level though they determine the allocation and planning based
on your needs, what priorities and which hospitals or which
health facilities get the dollars.
You can give it to entities besides hospitals, but I think
historically given the amounts it mostly went to hospitals to
work on. We thank you and Congress for giving us an extra
supplement of $90 million this year to put out for H1N1 which
was a supplement. I know CDC got some extra dollars as well. We
also did a small grant to many of the States on the health
volunteer program, the ESAR-VHP program, to kind of move that
ball along. So you are right though. We need to walk and chew
gum and have multiple use for these things and get the maximum
bang out of the buck here, and I think our State is doing a
great job and we are going to continue--whatever you provide,
we got a way to spend it and we will try to get the maximum out
of it to have localities prepared, which is what this is all
about.
Mr. Carney. So you are going to tell me how much more you
actually need then, right?
Dr. Pane. Write a check and we will spend it. We did a few
years ago have a partnership program which funded the Hershey--
--
Mr. Carney. Sure.
Dr. Pane. You know that, and we welcome your support and we
appreciate what you have done for us.
Mr. Carney. Okay. Well, I would like to thank the panel for
their testimony and for answering the questions we put before
them. I am almost certain that the subcommittee and perhaps the
larger committee will have further questions. We will address
them in a letter to you. Please respond in a timely fashion if
we do so. This panel stands adjourned. We will reconvene in 15
minutes. Thank you.
[Recess.]
Mr. Carney. The second panel will begin now and I would
like to welcome the second panel witnesses. Our first witness
is Dr. John Skiendzielewski. He serves as an emergency room
physician and Director of the Emergency Medicine Service Line
for the Geisinger Health System in Danville. He attended St.
Joseph's College and Temple University School of Medicine. He
has worked at Geisinger since finishing residency and served as
residency director before becoming department director. Dr.
Skiendzielewski served on the ACEP board of directors from 1998
to 2003. He has also published over 20 articles. He currently
lives in Danville, Pennsylvania with his wife, Kathleen.
Our second witness is Dr. Michael N. O'Keefe. Dr. O'Keefe
was appointed President and CEO of Evangelical Community
Hospital in September 2004 after serving the hospital
previously as Executive Vice President and Chief Operating
Officer, and Vice President of Operations. He holds a Master's
of Public Administration degree from the American University
and a Bachelor of Arts degree from St. Lawrence University of
Camden, New York. Prior to working at Evangelical, Dr. O'Keefe
served as Vice President for Operations at Newark-Wayne
Community Hospital in Newark, New York from 1984 to 1991, and
was the Administrative Assistant for Professional Services and
Director for Health-Related Services for the Community General
Hospital of Syracuse, in that position from 1977 to 1984. Dr.
O'Keefe lives in Lewisburg with his wife, Gail, and they have
three grown children.
Our third witness is Mr. Robert A. Kane, Jr. Mr. Kane has
worked at Susquehanna Health in many capacities since 1974. He
currently serves as the Vice President of Operations and is
responsible for the Williamsport Regional Medical Center's
emergency department, paramedic department, adult and pediatric
hospital program, the family medicine residency program, and
all of Susquehanna Health's emergency preparedness programs.
Bob has been managing many of these programs since 1988.
Pertinent education experience includes an MBA from Bucknell
University in 1996, a BS in Business Administration from Upper
Iowa University in 1984, Liberal Arts studies at Lycoming
College in 1981, a certification in the health care leadership
course at the Center for Domestic Preparedness from Aniston,
Alabama, 2006. We are familiar with all those places.
Our fourth witness has traveled to Pennsylvania from St.
Petersburg, Florida at the invitation of our Ranking Member,
Mr. Bilirakis. At this time, I will give Ranking Member
Bilirakis the pleasure of introducing his witness.
Mr. Bilirakis. Thank you, Mr. Chairman. I am pleased to
introduce Mr. Gary Carnes, President and CEO of All Children's
Health System in St. Petersburg, Florida. Mr. Carnes joined All
Children's Hospital in 1997 as its Executive Vice President and
Chief Operating Officer and has held his current position since
2002. Prior to his service with All Children's, Mr. Carnes held
positions at St. Anthony's Health Care and Ramsey Health Care
Corporation, another excellent institution. Mr. Carnes has a
Bachelor's of Science in Allied Health Professions and a
Master's of Business Administration in Finance. Founded in
1926, All Children's Hospital is the only specialty licensed
children's hospital on Florida's west coast. In 2007, it was
named for the fourth consecutive time among the top 25
children's hospitals in the United States and the best in
Florida by Child magazine.
Earlier this month, All Children's moved into its new
state-of-the-art facility. In addition to enhancing day-to-day
patient care, this new facility has features that will be
central during a natural disaster, terrorist act, or other mass
casualty event, God forbid we have one. For instance, the
emergency center and the new facility is more then triple the
size of the emergency room in the old hospital. The central
energy plant that is part of the new complex is designed to
keep the hospital fully functioning with air conditioning, and
of course in central Florida we got to have air conditioning,
for up to 3 weeks in the event of a disaster or power
interruption. In addition, the building's helipad was designed
to accommodate military aircraft which will enhance the
hospital's ability to receive patients arriving on all types of
helicopters during an emergency.
I welcome Mr. Carnes to our subcommittee. I look forward to
the unique perspective you will bring to this hearing. Thank
you, Mr. Chairman. I appreciate it.
Mr. Carney. Thank you, Mr. Bilirakis. If there is no
objection, I would like to submit for the record written
testimony that was received from the Hospital and Healthsystem
Association of Pennsylvania. Hearing no objection, the written
statement will be entered into the record.
[The information follows:]
Statement of The Hospital & Healthsystem Association of Pennsylvania
Submitted for the Record by Chairman Carney
January 25, 2010
The Hospital & Healthsystem Association of Pennsylvania (HAP)
represents and advocates for the more than 252 acute and specialty care
hospitals and health systems across the Commonwealth of Pennsylvania,
and the patients they serve. HAP appreciates the opportunity to present
testimony regarding closing the gap in medical surge capacity in
Pennsylvania, the Nation's sixth most populous State.
Pennsylvania's proximity to the Nation's capital and other
metropolitan areas, such as New York City, make it a vital part of the
Mid-Atlantic Region. However, these characteristics, combined with
Pennsylvania's unique geography, also make it vulnerable to natural and
man-made risk, along with being susceptible to the effects of a larger
regional incident.
Currently, health care systems are operating at or near capacity.
Rural, suburban, and urban areas in the commonwealth each face the
challenge of little flexibility for absorbing a substantial surge in
demand for care. Current guidance suggests that a community, including
hospitals, should be prepared to self-sustain for up to 72 to 96 hours
before Federal relief resources may arrive.
Federal money that has been allocated for medical surge has been
supportive of building medical surge capacity in Pennsylvania,
especially enhancing event management. Over the past several years,
hospitals have purchased decontamination units and supplies; radios for
communication, triage tags, and established limited stockpiles of
supplies and pharmaceuticals. Overarching emergency plans have been
developed and exercised. Lessons learned from exercises have provided
an opportunity to improve emergency plans and staff training. Hospitals
and health systems have been working on flexible strategies to
accommodate internal medical surge capacity. While hospitals have
thought about the flexibility to accommodate medical surge, capacity to
accommodate surge must continue to be expanded and grown.
The H1N1 outbreak illustrates how hospitals found the flexibility
to accommodate a medical surge. Hospitals established alternate
treatment sites for influenza-like illnesses outside of the emergency
department. One hospital used an adjacent building to the emergency
department to direct anyone with influenza-like illness to be screened
at that location before entering the emergency department. Other
hospitals established trailers on hospital property to be the sole
location to screen and treat influenza-like illness. Other hospitals
established clinics to treat influenza-like illness in other non-
patient care areas in their facility. As they worked to address
increased outpatient volume because of H1N1, hospitals used supplies
from their in-house stockpiles. Hospitals relied upon plans that were
exercised and revised. Staff was familiar with plans that were
activated due to training and exercises.
However, hospitals faced challenges during the H1N1 outbreak,
including supply shortages of N95 respirators and antiviral
pharmaceuticals. Some hospitals experienced double or more of normal
emergency department visits due to H1N1, stretching staff and other
resources as they cared for patients.
Continued Federal disaster preparedness funding will help hospitals
to expand medical surge in Pennsylvania. Dedicated funding for medical
surge capacity planning targeted to the regional level is critical.
Four key areas to focus expansion of medical surge capacity include
staff, resources, facilities, and infrastructure:
staffing
In Pennsylvania, there are multiple databases, such as SERVPA, to
access additional staff in a medical surge scenario. HAP suggests it is
appropriate to move forward from the databases to organizing and
training individuals listed in the databases for possible medical surge
scenarios.
resources
As the H1N1 outbreak grew, hospitals used their limited stockpile
of N95 respirators and antiviral pharmaceuticals. Hospitals shared the
challenges and concerns about the inability to receive ordered
materials due to a 6- to 8-month backorder. HAP suggests that public
policymakers examine avenues to provide a robust supply chain of needed
resources to health care facilities in the event of a peak demand that
could occur in an outbreak, such as H1N1, or in a major disaster.
facilities
Hospitals have examined ways to create surge capacity within their
own facilities and campuses. Hospitals also have worked with community
partners to determine where alternate care sites could be located. HAP
suggests that the multi-disciplined community planning efforts for
medical surge continue.
infrastructure
When hospitals surge into non-traditional patient care spaces, such
as a lobby, it is necessary to determine how to support the needs of
medical care that may occur there such as oxygen, suction, and cardiac
monitors. The same holds true if an alternate care site is opened in a
school or library. How is medical care supported in that venue? HAP
suggests that efforts should continue regarding how to support
alternate care sites on hospital campuses, as well as off-campus sites
such as a library or school.
HAP and its member hospitals and health systems appreciate the
opportunity to submit testimony and to provide the Pennsylvania
hospital and health system community's perspective on medical surge.
HAP supports continued Federal funding for disaster preparedness to
enable hospitals and health systems to respond to health care needs
that can arise during major public health crises, natural disasters, or
other disaster events.
HAP looks forward to future discussions on this important issue.
Mr. Carney. I would like to thank each of you witnesses for
your testimony. I will remind you that you will have 5 minutes
to sum up beginning with Dr. Skiendzielewski.
STATEMENT OF JOHN J. SKIENDZIELEWSKI, M.D., DIRECTOR, EMERGENCY
MEDICINE SERVICES, GEISINGER MEDICAL CENTER, DANVILLE,
PENNSYLVANIA
Dr. Skiendzielewski. Thank you. Good afternoon, Mr.
Chairman, and Mr. Bilirakis. I would first like to discuss
Geisinger's emergency preparedness efforts, and then outline
our efforts in conjunction with our community partners, and
conclude by offering several observations and recommendations.
Geisinger has a long and rich history of leadership and
disaster planning that dates back at least 30 years. At that
time we developed a five-county disaster plan and exercises
were conducted with a significant number of community partners.
Within a six-hospital consortium there were annual drills of
inter-hospital disasters. Since 1998, we have participated in
the east central Pennsylvania regional task force.
These counties worked to define groupings by their natural
mutual aid alliances. Each task force consists of
representatives from emergency medical services, law
enforcement, emergency management agencies, fire/rescue, and
hazardous material response teams. Our emergency management
programs are focused on addressing a wide variety of potential
disasters or incidents that may affect the community. These
include natural disasters, man-made disasters, and
technological events. We conduct an annual review of our hazard
vulnerability by considering incident probability, impact on a
facility, and services at our current preparedness level.
We have adopted a variety of response templates appropriate
to the disaster events that we might face. We drill and
exercise our response to many of these situations each year. In
addition to mass casualty trauma events a few other examples
include handling radiologically-contaminated injured patients,
decontamination of chemically-contaminated patients, as well as
floods, blizzards, and other internal and external disasters.
We have worked with both the State and Federal Government in
relation to the strategic National stockpile program. One of
the Pennsylvania Department of Health Medical Surge Equipment
Caches portable trailers is based at the Danville Ambulance
Service.
We have developed a detailed system-wide pandemic response
plan. This plan remains in effect today at this time due to the
H1N1 pandemic. We continue to focus on increasing our surge
capacity through development of alternate care-site plans. We
continue to serve as a non-metropolitan resource for patients
from terrorist acts that may occur. With five medical
helicopters, we can provide a redistribution function of
critical patients from other areas to our tertiary/quaternary
care centers. We have developed and maintained effective
relationships with our community partners, including local
fire, police, EMS, county emergency management, local emergency
planning committees, hospital support zone group, regional task
forces, and others.
With regard to emergency preparedness, the region
demonstrates a high level of collaboration rather than
competition. We have participated together with community
partners in joint planning, training, and exercise events.
Based on our emergency preparedness experience, I would like to
offer the committee several observations and recommendations to
consider to help strengthen hospital disaster planning and
response. No. 1, rural disaster planning and execution is
significantly different from urban disaster planning and
execution and poses significant and unique challenges. Our EMS
services are dependent to a great extent on volunteers making
attendance at planning meetings and participation in drills and
exercises very problematic. Our recommendation: Make additional
planning and coordination funds available to address the
specific emergency preparedness challenges faced by rural
health providers.
No. 2, the current medical surge equipment caches include
many items with finite shelf-life. Future emergency
preparedness funding may be exhausted simply to keep supply and
response equipment current. Our recommendation: Provide
dedicated supplemental funding to account for aging equipment
stockpiles that will need to be replaced. No. 3, the current
emergency preparedness grant funding formula that allocates
funding to hospital providers does not account for the size of
the facility's emergency department or if it has a trauma
center designation. Our recommendation: Amend the current
funding distribution formula to account for the size of the
hospital ED and for trauma center designations to appropriately
direct additional disaster funding to larger and more
specialized facilities.
No. 4, costly security measures and upgrades needed to deal
with disaster surge in at-risk locations have not been allowed
as approved grant expenditures for several years.
Recommendation: Authorize security and infrastructure
protection as acceptable expenditures under future emergency
preparedness grants. No. 5, we are in the process of developing
and implementing an electronic intensive care unit or e-ICU
program. As the e-ICU program grows and reaches out to regional
hospitals, it will become a valuable asset in confronting any
mass casualty disaster.
Our recommendation: Provide seed funding for e-ICU programs
to enhance image transfer capabilities, including connectivity
to regional hospitals to expand surge capacity. We appreciate
the support and direction that has allowed us to enhance our
disaster planning efforts over the recent years. Thank you, and
I will be happy to answer any questions you may have.
[The statement of Dr. Skiendzielewski follows:]
Prepared Statement of John J. Skiendzielewski
January 25, 2010
Good afternoon Congressman Carney and Members of the committee.
Thank you for the opportunity to comment on Geisinger Medical Center's
emergency preparedness efforts. My name is John Skiendzielewski and I
am an emergency medicine physician and director of the Emergency
Medicine Service Line for the Geisinger Health System in Danville. I am
joined today by Dr. Al Bothe, Geisinger Medical Center's executive VP
and chief medical officer.
Geisinger Health System is a fully-integrated health care delivery
system that includes a multidisciplinary physician group practice with
system-wide aligned goals, successful clinical programs, a robust
information technology platform, and an insurance product (Geisinger
Health Plan). Geisinger's service area covers a 41-county region in
central and northeastern Pennsylvania with a population of
approximately 2.6 million. Research, education, and community service
are also integral parts of Geisinger's mission. Geisinger Medical
Center in Danville is the system's flagship hospital. Geisinger Medical
Center is the region's tertiary/quaternary care hospital. It is staffed
by more than 350 specialists and subspecialists and is the education
site for residents and fellows in 28 specialties. The medical center is
home to a Level I trauma center with a pediatric designation, centers
for heart, cancer, and brain diseases, stroke and transplant programs
and the Janet Weis Children's Hospital, Weis Research Center, and the
Henry Hood Center for Health Research.
I would first like to discuss Geisinger's emergency preparedness
efforts and then outline our efforts in conjunction with our community
partners and conclude by offering several observations and
recommendations.
Geisinger has a long and rich history of leadership in disaster
planning that dates back at least 30 years. At that time, a regional 5-
county disaster plan was developed, and exercises were conducted with a
significant number of community partners. Within a 6-hospital
consortium, there were annual drills of inter-hospital disasters,
including triage exercises and inter-hospital communications.
Since 1998, we have participated in the East Central PA Regional
Task Force (ECTF) that was formed in response to the threat of the use
of weapons of mass destruction. This is one of nine regional task
forces in Pennsylvania, originally known as Regional Counter-Terrorism
Task Forces. The counties worked to define groupings by their natural
mutual aid alliances. Each task force consists of representatives from
emergency medical services, law enforcement, emergency management
agencies, fire/rescue, and hazardous material response teams. This is a
partnership with various State and Federal officials having regional
responsibilities from such agencies as the Federal Bureau of
Investigation, Bureau of Alcohol, Tobacco, and Firearms, Pennsylvania
State Police, National Guard, Environmental Protection, and others.
Since 9/11/2001, we have adopted a command and response system
known as the Hospital Incident Command System. This system is modeled
after and integrated with the National Incident Management Framework.
Funded through Federal emergency funds, numerous employees have
received disaster training as well as on response procedures for a wide
variety of disaster types.
Our emergency management programs are focused on addressing a wide
variety of potential disasters or incidents that may affect the medical
community. These include natural disasters, man-made disasters, and
technological events. We conduct an annual review of our hazard
vulnerability by considering incident probability, impact on the
facility and services, and the current preparedness level. We develop
and modify our emergency response plans based upon risk determination
that is ranked using this methodology. We have adopted a variety of
response templates appropriate to the disaster events we might face. We
drill and exercise our response to many of these situations each year.
In addition to mass casualty/trauma events, a few other examples
include handling radiologically-contaminated injured patients,
decontamination of chemically-contaminated patients, as well as floods,
blizzards, and other internal and external disasters.
A number of emergency communication enhancement projects have been
completed. These include the establishment of the State-wide radio
system linking hospitals and emergency response agencies and the
establishment of the Facility Resource Emergency Database or FRED.
These tools provide additional valuable key links to enhance
communication and coordination activities during a disaster.
We have worked with both the State and Federal government in
relation to the strategic National stockpile program. This program is
beneficial when disasters generate an increased need for supplies and
medications beyond what may be available through normal vendor
channels. One of the Pennsylvania Department of Health MSEC (Medical
Surge Equipment Cache) portable trailers is based at Danville's
Ambulance Service's station. In addition, we provide medical direction
to Danville Ambulance and other EMS units (including ambulances,
tactical police medical units, and police department defibrillator
programs).
We have developed a detailed system-wide pandemic response plan.
This plan remains in effect at this time due to the H1N1 pandemic. This
information is also shared with surrounding hospitals and higher
education institutions.
We continue to focus on increasing our surge capacity through
development of alternate care site plans. Also, we have focused on
increasing our self-sustainability during a disaster.
We continue to serve as a non-metropolitan resource for patients
from terrorist acts that may occur near us. With 5 medical helicopters,
we can provide a redistribution function of critical patients from
other areas to our tertiary/quaternary care centers.
We have developed and maintained effective relationships with our
community partners, including local Fire, Police, EMS, County Emergency
Management, Local Emergency Planning Committees, Hospital Support Zone
Group, Regional Task Forces, and others. With regard to emergency
preparedness, the region demonstrates a high level of collaboration
rather than competition. We have participated together with community
partners in joint planning, training, and exercise events. We have
established memorandums of understanding or MOU's with the regional
task forces. These documents provide guidelines for the sharing of
equipment and staff in disaster situations. Within our task force, 16
hospitals have signed the MOU.
We have developed local hospital support zones. For example, the
local zone that includes Danville involves 8 hospitals, emergency
management agencies, visiting nurse agencies, the American Red Cross
and others. This is a sub-set of the 7-county task force. The support
zone serves as a valuable forum for sharing information, planning, and
support activity. This group generally meets 4 times per year.
Based on our emergency preparedness experience I would like to
offer the committee several observations and recommendations to
consider to help strengthen hospital disaster planning and response.
(1) Rural disaster planning and execution is significantly
different from urban disaster planning and execution and poses
significant and unique challenges. For the most part rural
areas in the Commonwealth do not have large county-wide police,
fire, or EMS services. They are also dependent to a greater
extent on volunteers to provide a wide range of response
services making attendance at planning meetings and
participation in drills and exercises problematical. Most small
to mid-size rural hospitals do not have staff dedicated to
emergency management nor do they have specific emergency
management budgets.
Recommendation.--Make additional planning and coordination funds
available to address the specific emergency preparedness
challenges faced by rural health providers.
(2) The current medical surge equipment caches include items with
finite shelf life. Items such as protective gear, medical
supplies and battery-powered sources have expiration dates that
will increasingly require replacement of aging stockpiles.
Future emergency preparedness funding make be exhausted simply
to keep supply and response equipment current.
Recommendation.--Provide dedicated supplemental funding to account
for aging equipment stockpiles that will need to be replaced.
(3) The current emergency preparedness grant funding formula that
allocates funding to hospital providers does not account for
the size of the facility's emergency department or if it has a
trauma center designation. This ``one-size-fits-all'' approach
does not adequately direct emergency preparedness funding to
larger facilities that would be expected to handle a larger
proportion of disaster cases.
Recommendation.--Amend the current funding distribution formula to
account for the size of the hospital ED and for trauma center
designations to appropriately direct additional disaster
funding to larger facilities.
(4) Security measures and upgrades needed to deal with disaster
surges in at-risk locations including access controls,
surveillance cameras, biometric ID systems and related
equipment are costly but have not been allowed as approved
grant expenditures for several years.
Recommendation.--Authorize security and infrastructure protection
as acceptable expenditures under future emergency preparedness
grants.
(5) One critical shortage in our region is the lack of specialized
hospital facilities to care for burn patients. Currently,
Geisinger and other hospital emergency departments are
initially treating and stabilizing burn patients in preparation
of transfers to recognized burn centers out of the region. We
are in the process of developing and implementing an electronic
intensive care unit (``e-ICU'') program to link by telemedicine
to the burn unit at Lehigh Valley Hospital. As the e-ICU
program grows and reaches out to regional hospitals it will
become a valuable asset in confronting any mass casualty
disaster.
Recommendation.--Provide evaluation and planning resources to
consider the status of burn patients within the region. Provide
seed funding for e-ICU programs to enhance image transfer
capabilities, including connectivity to regional hospitals to
expand surge capacity.
We appreciate the support and direction that has allowed us to
enhance our disaster planning efforts over the recent years. We hope
that our input here today helps in crafting future response
capabilities to meet and mitigate the potential hazards and disasters
that we may face in the future. Thank you. Dr. Bothe and I would be
happy to answer any questions you may have.
Mr. Carney. Thank you. Dr. O'Keefe for 5 minutes, please.
STATEMENT OF MICHAEL N. O'KEEFE, PRESIDENT AND CHIEF EXECUTIVE
OFFICER, EVANGELICAL COMMUNITY HOSPITAL, LEWISBURG,
PENNSYLVANIA
Mr. O'Keefe. Good afternoon. Thank you for your invitation
to testify today. If I may, let the record show Dr. O'Keefe was
my father. I am Michael O'Keefe. I serve as the Chief Executive
Officer of Evangelical Community Hospital in Lewisburg,
Pennsylvania in Union County. First, I want the Subcommittee on
Homeland Security and the State and Federal taxpayers to be
assured that the resources that have been allocated for
preparedness especially since 9/11 have not been wasted. Since
that time, there has been much attention paid and advances made
in the application of technology, surge capacity, security,
communication, collaboration between and among State, regional,
and local agencies and organizations.
Pre-9/11 conditions. The inception of the Regional Counter
Terrorism Task Forces actually began in 1999. Through funding
from PEMA, the nine regional State-wide groups began to conduct
meetings and explore ways to coordinate and acquire equipment
and supplies that would have interoperability within the
counties. In the north central region hospitals and other
agencies were not included in the early stages. PEMA monies
were primarily used to fund meetings for the county emergency
management coordinators, not to purchase supplies or expand
outreach to other agencies.
Prior to 9/11 Evangelical Community Hospital had little
focus on terrorism. The concept of preparing for a chemical,
biological, radiological, or nuclear explosive or CBRNE event
was extremely remote. The hospital, relatively speaking, had
not personal protective equipment for such an event. There was
no facility, fixed or portable, for mass decontamination nor
were there any plans in place or exercises done. It is probably
safe to assume that most rural hospitals were in similar
situations. In addition, the means for mass communications were
poor. During inter-hospital disaster drills the priority
complaint was always lack of communication. The category that
was rated the most important, yet rated the lowest. In those
pre-9/11 drills the mass casualty events were almost always
some type of wreckage and occasionally a small amount of
hazardous material was included. Exercising for chemical,
biological, radiological, nuclear explosive was never even
considered.
Post-9/11. After 9/11 the regional task force realized the
need to include more agencies and give them a more prominent
role. Committees were formed around law enforcement, fire,
search and rescue, hazardous materials, hospitals and pre-
hospital services, training, and equipment. Each committee
appointed a chair that reported to an executive board. After
the creation of the Department of Homeland Security, funding
for the regional counterterrorism task force came from the
Federal Government and no longer from the State agency, even
though funds were still distributed through PEMA. This Federal
funding allows a large amount of dollars to come into the
individual regions.
A small amount is used for administration and the remainder
is dedicated to the purchase of equipment and supplies for each
of the previously-mentioned committees. The equipment purchased
includes such items as decontamination trailers, mass casualty
trailers, hazardous materials trailers, and prime movers. Just
recently oxygen generators were purchased for each mass
casualty trailer. There is a state-of-the-art mobile Incident
Command Post for the region. There is a mass fatality trailer
and high-tech hospital monitoring detection equipment.
Supplies have been purchased that meet specific needs of
each committee. In addition to supplies, personal protection
equipment have been provided to outfit the many region wide
responders who may be dispatched. Training is the second pillar
necessary for a reliable response. In the years just after 9/11
it was evident that materials for response were greatly lacking
and most of our funding was applied to those needs. Training
was not the main concern. However, in the past 2 years North
Central Regional Task Force has devoted as substantial amount
of their budget to supporting training. Region-wide drills can
be extremely costly. Nonetheless, consultants were hired to
develop and manage major exercises. These included two
Strategic National Stockpile drills, and a mass casualty drill
has been contracted for the spring. This has all resulted from
the focus of the Department of Homeland Security since 9/11.
Preparedness has indeed been enhanced.
For hospitals, after the creation of the Department of
Homeland Security, funding streams were made available to other
agencies in addition to the equipment and supplies that were
available through the regional task forces. The Pennsylvania
Department of Health received Federal monies that are
distributed to each of the State's hospitals. Previously known
as the HRSA Grant, the grant is now known as the Hospital
Preparedness Program or HPP. Since its inception in 2003
Evangelical Community Hospital has purchased level B and level
C personal protective equipment. There is enough level C
equipment to suit 40 Emergency Department staff for response to
a CBRNE event. Evangelical Hospital now has six level III
hazardous materials technicians certified through the HPP
grants and enough level B personal protective equipment to
outfit all of them. There are additional level C hazardous
materials techs working as paramedics but most of them were
trained prior to
9/11.
Funding has also enabled Evangelical Community Hospital to
build state-or-the-art fixed decontamination facility. It has a
dedicated HVAC system that extends to an isolation room in the
Emergency Department. This will protect the hospital from
secondary contamination. It includes a holding tank to capture
possible contaminated water and other products that will drain
during the decontamination process. As stated, Evangelical
Hospital now had a certified team to manage decontamination
operations. Decontamination surge capacity can also be
increased by mutual aid with a local fire department, the
county EMA, and the Bureau of Prisons in Lewisburg. This
provides additional certified manpower along with a nine-
station portable contamination system.
Prior to 9/11 Evangelical Hospital had no pharmaceutical
stockpile in the event of a pandemic. Through HPP funds the
hospital pharmacy now maintains a cache large enough to support
the hospital's staff and their immediate families. Once again,
this contributes to our surge capacity by enabling more staff
to respond. A large cache of antibiotics is also on hand to
protect staff in the event of a bio-terrorism attack. A mandate
from the Department of Health requires recipients of the HPP
Grant to have surge capacity of 20 percent of their census.
With 133 licensed beds Evangelical Hospital exceeds that goal
with 27 beds available. The hospital has purchased enough beds
and cots for mass care, as well as supplies designed to
supplement a surge. We have also designed plans to surge up to
170 casualties above our census.
Mr. Carney. Mr. O'Keefe, if you could wrap it up.
Mr. O'Keefe. Thank you.
[The statement of Mr. O'Keefe follows:]
Prepared Statement of Michael N. O'Keefe
January 25, 2010
Members of the U.S. House of Representatives Committee on Homeland
Security: Thank you for your invitation to testify. My name is Michael
O'Keefe and I serve as CEO at Evangelical Community Hospital in
Lewisburg, PA, Union County.
I understood our charge today is to discuss the steps that area
hospitals have taken to prepare in the event of either a natural
disaster or an act of terrorism. Specifically, are local hospitals
ready? What challenges exist regarding our current medical and surgical
capacity? And, can we identify ways to improve coordination among
affected organizations?
First, I want the subcommittee on Homeland Security and the State
and Federal taxpayers to be assured that the resources that have been
allocated for preparedness, especially since 9/11, have not been
wasted. Since that time, there has been much attention paid and
advances made in the application of technology, surge capacity,
security, communications, and collaboration between and among State,
regional, and local agencies and organizations.
i. pre-9/11 conditions
Regional Counter Terrorism Task Forces
The inception of the Regional Counter Terrorism Task Forces
actually began in 1999. Through funding from PEMA, the nine regional
State-wide groups began to conduct meetings and explore ways to
coordinate and acquire equipment and supplies that would have
interoperability within the counties. In the North Central region
hospitals and other agencies were not included in the early stages.
PEMA monies were primarily used to fund meetings for the county
emergency management coordinators, not to purchase supplies or expand
outreach to other agencies.
Hospitals
Prior to 9/11 Evangelical Community Hospital had little focus on
terrorism. The concept of preparing for a chemical, biological,
radiological, nuclear explosive (CBRNE) event was extremely remote. The
hospital, relatively speaking, had no personal protective equipment
(PPE) for such an event. There was no facility, fixed or portable, for
mass decontamination nor were any plans in place or exercises done. It
is probably safe to assume that most rural hospital were in similar
situations.
In addition, the means for mass communication were poor. During
inter-hospital disaster drills the priority complaint was always lack
of communication. The category that was rated the most important, yet
rated the lowest. In those pre-9/11 drills the mass casualty event was
always some type of wreckage and occasionally a small amount of
hazardous materials was included. Exercising for chemical, biological,
radiological, nuclear explosive (CBRNE) was never considered.
ii.post-9/11
Expansion of the North Central Counter Terrorism Task Force
After 9/11 the regional task force realized the need to include
more agencies and to give them a more prominent role. Committees were
formed around law enforcement, fire, search and rescue, hazardous
materials, hospitals and pre-hospital services, training, and
equipment. Each committee appointed a chair that reported to an
executive board.
After the creation of the Department of Homeland Security, funding
for the regional counterterrorism taskforce came from the Federal
Government and no longer from the State agency, even though funds are
still distributed through PEMA. This Federal funding allows a large
amount of dollars to come into the individual regions. A small amount
is used for administration and the remainder is dedicated to the
purchase of equipment and supplies for each of the previously mentioned
committees. This can be a complicated process.
Equipment purchased includes such items as decontamination
trailers, mass casualty trailers, hazardous materials trailers, prime
movers. Just recently oxygen generators were purchased for each mass
casualty trailer. There is a state-of-the-art mobile Incident Command
Post for the region. There is a mass fatality trailer and high-tech
hospital monitoring and detection equipment.
Supplies have been purchased that meet the specific need of each
committee. In addition to supplies, personal protection equipment (PPE)
has been provided to outfit the many region-wide responders who may be
dispatched.
Training is the second pillar necessary for a reliable response. In
the years just after 9/11 it was evident that materials for response
were greatly lacking and most of the funding was applied to those
needs. Training was not the main concern. However, in the past 2 years
North Central Regional Task Force has devoted a substantial amount of
their budget to supporting training. Region-wide drills can be
extremely costly. Nonetheless, consultants were hired to develop and
manage major exercises. These included two Strategic National Stockpile
drills. A mass casualty drill has been contracted for the spring.
This has all resulted from the focus of the Department of Homeland
Security since 9/11. Preparedness has indeed been enhanced.
Hospitals
After the creation of the Department of Homeland Security, funding
streams were made available to other agencies in addition to the
equipment and supplies that were available through the regional task
forces. The PA Department of Health receives Federal monies that are
distributed to each of the State's hospitals. Previously known as the
HRSA Grant, the grant is now known as the Hospital Preparedness Program
or HPP. Since its inception in 2003 Evangelical Community Hospital has
purchased ``level B'' and ``level C'' personal protective equipment
(PPE). There is enough ``level C'' to suit 40 Emergency Department
staff for response to a CBRNE event. Evangelical Community Hospital now
has 6 level III hazardous materials technicians certified through the
HPP grants and enough ``level B'' PPE to outfit all of them. There are
additional level C hazardous materials techs working as paramedics but
most of them were pre-9/11.
Funding has also enabled Evangelical Community Hospital to build a
state-of-the-art fixed decontamination facility. It has a dedicated
HVAC system that extends to an isolation room in the Emergency
Department. This will protect the Hospital from secondary
contamination. It includes a holding tank to capture possible
contaminated water and product that will drain during the
decontamination process. As stated, Evangelical Community Hospital now
has a certified team to manage decontamination operations.
Decontamination surge capacity can also be increased by mutual aid with
the local fire department, the county EMA, and the Bureau of Prisons at
Lewisburg. That provides additional certified manpower along with a 9-
station portable decontamination system.
Prior to 9/11 Evangelical Community Hospital had no pharmaceutical
stockpile in the event of a pandemic. Through HPP funds the Hospital
pharmacy now maintains a cache large enough to support the hospital's
staff and their immediate families. Once again, this contributes to our
surge capabilities by enabling more staff to respond. A large cache of
antibiotic is also on hand to protect staff in the event of bio-
terrorism attack.
A mandate from the Pennsylvania Department of Health requires
recipients of the HPP Grant to have surge capacity for 20% of their
census. With 133 licensed beds, Evangelical Community Hospital exceeds
that goal with 27 beds available. The hospital has purchased enough
beds and cots for mass care, as well as supplies designed to supplement
a surge. We have also designed plans to surge up to 170 casualties
above census.
One percent of HPP funds are required to be spent on training and
exercises. This year's grant funding provides $450.00 for training.
Evangelical Community Hospital far exceeds the $450 allocated for
training when executing just one drill. Our hazardous materials drill
held annually during the Little League World Series involves
Evangelical Community Hospital staff and coordinates with nine other
agencies including the Red Cross, PEMA, Lewisburg Board of Prisons,
Union County EMA, Bucknell University, local Fire Departments and local
businesses. This type of coordination and outreach by a small rural
hospital was never even considered prior to 9/11.
Other areas that have vastly improved since 2001 are communication
and technology. As previously stated, communication is always the most
critical yet poorest performing function of disaster preparedness.
Since 9/11 the hospital has acquired the 800 MHz radio along with
``biokey''. That system is located in the hospital's relatively new
command center. Additional med radios have been purchased to aid pre-
hospital services in a surge response. At no expense to the hospital.
Evangelical Community Hospital, along with all PA hospitals, now
subscribe to technological communication systems such as Realtime
Outbreak Disease Surveillance (RODS), Facility Resource Electronic Data
(FRED), Infection Surveillance (PA Neiss), and mass reporting (PA Han).
Hospitals have also acquired a Telephone Priority Service (TPS).
iii. where do we stand today
Response Reliability
Since 9/11 hospitals have been provided an opportunity to obtain a
large inventory of supplies and equipment. Hospitals in the NCTF have
been given the privilege of training and exercising with some of this
inventory.
However, a critical concern is response reliability. Real-time
response in disasters such as Katrina have shown that 50% to 80% of
responders and health care workers will not report to work if there is
a perceived threat to their immediate families. Responder support must
not be assumed or taken for granted.
For example, when Evangelical Community Hospital sets up a 9-
station decontamination system we are prepared to handle approximately
100 casualties in an hour. But there are never enough responders to
work all nine stations. Our decontamination rate is cut dramatically.
Would this occur in a real CBRNE event? It is a difficult question to
answer. Without enough responders all the equipment, supplies, and
technology go unused. Careful planning breaks down and a course for
failure begins to spiral.
There is no easy solution. Response reliability stands as the most
critical yet most questionable unmet need. Hospitals are much better
prepared in the categories of supplies, equipment, pharmacy caches,
communications, etc. If there is a topic of concern that Pennsylvania
needs to focus upon today, it is finding a solution to response
reliability.
In closing, on behalf of Evangelical Community Hospital and our
Director of Environmental Safety and Security, I am confident that the
Hospital is committed to disaster preparedness, as well as execution
should disaster or terrorism strike. We remain steadfast in our
partnerships and collaborations with State, county, and township
officials, as well as with our membership in the North Central and East
Central Task Forces.
Mr. Carney. Mr. Kane, please, for 5 minutes.
STATEMENT OF ROBERT A. KANE, JR., VICE PRESIDENT OF OPERATIONS,
SUSQUEHANNA HEALTH, WILLIAMSPORT, PENNSYLVANIA
Mr. Kane. I would like to thank Chairman Carney and
committee Members for the opportunity to provide this
testimony. This topic is at the forefront of our emergency
preparedness efforts at Susquehanna Health. I am representing
Susquehanna Health in Williamsport, which is made up of
Williamsport Hospital, Divine Providence Hospital and our
Critical Care Hospital, Muncy Valley. Our emergency
preparedness planning has a long history of understanding the
serious consequences of disasters being at the forefront of
disaster preparation. In 1989 we opened the region's first
hazardous materials decontamination center and it had been in a
continual state of readiness since. Hurricane Gustav hit
Louisiana in September, 2008 and Susquehanna Health sent
personnel to aid in hospital evacuations the days before and
after the storm hit.
Our Prehospital Medical Director and emergency room
physician, Dr. Frailey, who is with me here today, provided
medical direction for our team. Dr. Frailey is one of our
regional experts with the following experience: 25 years as a
naval flight surgeon and primary responsibilities to preplan
for mass casualty incidents, a medical specialist with
Pennsylvania Task Force One, the regional medical director in
Lycoming, Tioga, and Sullivan County, and instructs advanced
life support, international trauma life support, PEMA blast
injuries, forensics, and crush injury classes and many others.
In 2009, the Department of Health purchased portable
hospitals to assist regions in their readiness. We were the
first in the State to set up and use the portable hospitals to
prepare for the biggest threat to our region in regards to mass
casualty, the Little League World Series. Every August,
Williamsport is in the international spotlight which carries a
heavy responsibility for our emergency preparedness team to
accurately forecast and to take the necessary steps to mitigate
potential man-made or natural disasters. Little League World
Series more than doubles the population of Williamsport and a
mass casualty incident is a very real danger that we must
consider.
We are here today to outline several key areas that would
be relevant to your House subcommittee. In many ways,
Susquehanna Health is prepared to deal with a mass casualty
incident that happens in our community. Annually, we meet with
our community partners to identify external vulnerabilities and
update our emergency operations plan to mitigate these threats.
Our surge capacity is assessed and systems including pre-
defined locations throughout our three hospitals. Full-scale
exercises and drills identify our areas for improvement and
practices. ASPR grant funding helps to mitigate our identified
needs regarding supplies and equipment. Our planning efforts
also identify our own internal vulnerabilities.
Our two emergency departments serve over 60,000 patients a
year with 43 treatment rooms. Susquehanna Health has started a
major construction project that will nearly double our
emergency department treatment capability. Our geographic
location as a regional population center in the heart of a
large rural tract implies that we will only be able to depend
on ourselves to service our population during the initial
stages of a mass casualty incident. Lycoming County contains
over 1,200 square miles of territory. Our closest trauma center
is 45 minutes away by ground. During a mass casualty, we, and
many other rural facilities will be challenged to maintain
nurse-to-patient ratios, particularly during a sustained
incident such as a pandemic.
In July, 2009, Pennsylvania initiated a ban on mandatory
overtime. While this is lauded as a positive step forward in
protecting health care workers and patients, its wording places
burdens on emergency preparedness. In response to the many
factors effecting health care organizations nationally,
hospitals are becoming leaner in staffing, thereby reducing any
depth for initial and sustained mass casualty operations. Any
expectation of rural hospitals to staff alternate care sites
during an event is unrealistic and would further deplete our
nurse-to-patient ratios and jeopardize patients and staff. Many
hospitals, Susquehanna Health included, use a just-in-time
supply inventory system due to limited storage space and as a
cost savings measure. This limits us further during a sustained
mass casualty incident.
In general, open space to expand services into is limited
throughout our hospitals. Specialty centers within hospitals
have their own unique regulations that further limit our
available spaces. Severe weather and mountainous terrain are
identified as hazards and can also be contributing factors
delaying aid to our region in a disaster. Our finite community
resources force us to plan on little to no law enforcement or
security available during a mass casualty incident. Lack of
immunity from prosecution to physicians and other health care
providers may further limit our response to a disaster for fear
of prosecution.
This statement also holds true in regards to our rural
hospitals receiving casualties from a disaster in a large
population center. If a mass casualty event happened in a large
population center and we were asked to receive patients from
it, we would have time to prepare ourselves and to set up our
surge beds, create real-time staffing plans, and work with our
community providers.
Mr. Carney. Mr. Kane, thank you. You are at 6 minutes now.
Mr. Kane. Okay.
[The statement of Mr. Kane follows:]
Prepared Statement of Robert A. Kane, Jr.
January 25, 2010
I would like to thank Chairman Carney and committee Members for the
opportunity to provide this testimony regarding the medical community
and medical surge capacity. This topic is at the forefront of our
emergency preparedness efforts at Susquehanna Health. I am representing
Susquehanna Health in Williamsport which is made up of Williamsport
Hospital, Divine Providence Hospital, and our Critical Access Hospital,
Muncy Valley. Our emergency preparedness planning has a long history of
understanding the serious consequences of disasters and being at the
forefront of disaster preparation. In 1989 we opened the region's first
hazardous materials decon center and it has been in continual state of
readiness since. Hurricane Gustav hit Louisiana in September, 2008 and
Susquehanna Health sent personnel to aid in hospital evacuations the
days before and after the storm hit. Our Prehospital Medical Director
and emergency room physician, Dr. Greg Frailey provided medical
direction for our team. Dr. Frailey is one of our regional experts with
the following experience: 25 years as a naval flight surgeon and
primary responsibilities to preplan for Mass Casualty Incidents, a
medical specialist with Pennsylvania Task Force One, the regional
medical director in Lycoming, Tioga, and Sullivan County, and instructs
Advanced Trauma Life Support, International Trauma Life Support, PEMA
blast injuries, forensics, and crush injury classes and many others. In
2009 the Department of Health purchased portable hospitals to assist
regions in their readiness. We were the first in the State to set up
and use the portable hospitals to prepare for the biggest threat to our
region in regards to mass casualty: The Little League World Series.
Every August, Williamsport is in the international spotlight which
carries a heavy responsibility for our emergency preparedness team to
accurately forecast and take the necessary steps to mitigate potential
man-made or natural disasters. Little League World Series more than
doubles the population of Williamsport and a Mass Casualty Incident
(MCI) is a very real danger that we must consider.
We're here today to outline several key areas that would be
relevant to your House Subcommittee. In many ways Susquehanna Health is
prepared to deal with a mass casualty incident that happens in our
community. Annually, we meet with our community partners to identify
external vulnerabilities and update our emergency operations plan to
mitigate these threats. Our surge capacity is assessed and mass
casualty plans are updated at this time as well. Surge beds are
identified in our clinical data systems including pre-defined locations
throughout our three hospitals. Full-scale exercises and drills
identify our areas for improvement and best practices. Assistant
Secretary for Preparedness and Response (ASPR) grant funding helps us
mitigate our identified needs regarding supplies and equipment. Our
planning efforts also identify our own internal vulnerabilities.
Our two emergency departments serve over 60,000 patients a year
with 43 treatment rooms. Susquehanna Health has started a major
construction project that will nearly double our emergency department
treatment capacity. Our geographic location as a regional population
center in the heart of a large rural tract implies that we will only be
able to depend on ourselves to service our population during the
initial stages of an MCI. Lycoming County contains over 1,200 square
miles of territory. Our closest trauma center is 45 minutes away by
ground. During a Mass Casualty, we, and many other rural facilities,
will be challenged to maintain nurse-to-patient ratios, particularly
during a sustained incident such as a pandemic. In July, 2009,
Pennsylvania initiated a ban on mandatory over time. While this is
lauded as a positive step forward in protecting health care workers and
patients, its wording places burdens on emergency preparedness.
In response to the many factors affecting health care organizations
nationally, hospitals are becoming ``leaner'' in staffing, thereby
reducing any depth for initial and sustained MCI operations. Any
expectation of rural hospitals to staff alternate care sites during an
MCI is unrealistic and would further deplete our nurse-to-patient
ratios and jeopardize patients and staff. Many hospitals, SH included,
use a just-in-time supply inventory system due to limited storage space
and as a cost-savings measure. This limits us even further during a
sustained mass casualty incident. In general, open space to expand
services into is limited throughout our hospitals. Specialty centers
within hospitals have their own unique regulations that further limit
our available spaces. Severe weather and mountainous terrain are
identified as hazards and can also be contributing factors delaying aid
to our region in a disaster. Our finite community resources force us to
plan on little to no law enforcement or security available during an
MCI. Lack of immunity from prosecution to physicians and other health
care providers may further limit our response to a disaster for fear of
prosecution.
This statement also holds true in regards to our rural hospitals
receiving casualties from a disaster in a large population center. If
an MCI happened in a large population center and we were asked to
receive patients from it, we would have time to prepare ourselves and
set up our surge beds, create real-time staffing plans, and work with
our community partners. Our limitations to offer assistance would
include our liability concerns, and the ban on mandatory overtime.
Would we be able to mandate staff overtime if the disaster was declared
in another community and didn't directly affect us? Additionally, with
few exceptions, there is no current memorandum of understandings
between our regional hospitals and others around the State.
The information and direction coming from the Federal Government
helps to define the expectations for MCI preparation. The Center for
Domestic Preparedness in Anniston, Alabama offers high quality and
targeted training on the impact of disasters on hospitals and other
organizations. SH has sent 40 staff for training at the CDP and
continues to schedule our leadership to prepare us for the future and
stay up-to-date on the latest trends and best practices. The National
Incident Management System (NIMS) courses help tie our National
disaster response to the local efforts of all agencies involved and
helps define everyone's responsibilities. The NIMS concept is very
broad-based and offers a defined framework for response. It also leads
to confusion at the local level and Federal agencies give conflicting
guidance on matching training to positions in health care
organizations. Much of the NIMS training is geared towards the fire
service. We have made great strides towards full NIMS integration with
our community partners but further development is needed to adapt NIMS
to health care organizations.
Health care looks to the State and Federal Government to help
satisfy our unmet needs during a disaster or MCI. What can the State
and Federal Government do to help?
Currently we are under the conflicting purview of many
regulatory agencies to include the Joint Commission, Department
of Health, PEMA, FEMA, DHS, HHS, and CMS, all with independent
views, and competing interests. Give health care an equal voice
in these organizations to ensure that health care needs are
anticipated and met.
Immediate clinical and support staffing during an MCI.
Financial support to stockpile medications and equipment for
an MCI and rapid delivery of additional medical supplies.
Rapid and mass airlift capabilities with the ability to
handle critical patients.
Rapid deployment of an incident management team or liaisons
to hospitals in the initial hours of a disaster with the
authority to request Federal resources.
National phone banks/information hotlines to assist
overburdened hospital staff during an MCI or disaster. Rural
hospitals will not have the physical capability to handle the
volumes of phone calls associated with an MCI.
Ease EMTALA regulations during a disaster that is not
Federally or State-declared.
Provide funding for Information Technology emergency
communication initiatives to support the transfer of patients,
and, give care to patients not known to the health care entity.
Insure all rural hospitals have employee mass notification
systems in place.
Provide Federal templates for health care emergency
operations plans and mass casualty incident management to be
adopted at the State and local levels.
Provide funding, mandates, and direction to local health
care (not necessarily associated with hospitals) in the
planning for mass casualty care. For example: Medical offices,
surgery centers, GI centers, eye centers all have nursing,
physicians, and other health care workers, but won't
necessarily make themselves available to help a hospital if
there is a disaster since they are not mandated to do so.
In closing, I would like to thank Chairman Carney and committee
Members for the opportunity to provide this testimony and Congressman
Carney's staff for their assistance and guidance. Susquehanna Health
considers itself fortunate to be able to maintain a high degree of
emergency preparedness, but we also acknowledge the obstacles we face
as a rural health care system with finite human and material resources
at hand. Our efforts in planning and hazard mitigation can only sustain
us in the short term and we will look to our State and Federal
officials for a rapid and coordinated response to assist us should the
need arise.
Mr. Carney. Mr. Carnes, please, for 5 minutes, 5 minutes.
STATEMENT OF GARY A. CARNES, PRESIDENT AND CHIEF EXECUTIVE
OFFICER, ALL CHILDREN'S HEALTH SYSTEM, ST. PETERSBURG, FLORIDA
Mr. Carnes. Thank you, Mr. Chairman and Mr. Bilirakis, for
inviting me, and to this subcommittee. I think actually
Congressman Bilirakis gave most of my summary when he
introduced me. I am here representing primarily children in the
land of hurricanes. But remember in Haiti 50 percent of the
population is under 18 years of age, so children are a huge
factor in disasters and often overlooked. Emergency
preparedness is not something that happens when an impending
incident is out there. It must be built in to design staffing
and it must be funded. Not all hospitals will be equally called
upon during a disaster. Safety net hospitals, which is what we
refer to them in Florida, freestanding children's hospitals,
trauma centers, universities, sole community providers almost
always get the first wave of victims during any kind of
disaster or incident.
The integrity of the building and maintenance of public
utilities is not assured at all as we saw in Katrina. Buildings
were often intact but nobody could, and if there were no
utilities to care for patients and therefore patients had to be
removed by helicopter from many, many facilities. It took a
long, long time to remove those patients. Lack of heating,
ventilating, and air conditioning makes hospitals mostly
unusable and in fact causes them to become a sick building over
time. Few hospitals in the United States can maintain 100
percent of their utilities. Most States require only basic
emergency electric circuits, red plugs, as we call them in the
business, to be maintained.
Patient receipt and removal is a key as you saw in Katrina.
Clinical readiness is another issue. The required medical and
surgical expertise doesn't just happen. It must be recruited,
paid to be retained, on call and available, and has to be kept
current for its skills. A little bit about the All Children's
story. We just opened less than a month ago a brand new 259-bed
quaternary regional freestanding pediatric facility and
ambulatory complex. The cost was $403 million. Protection was
providing category 4 and 5 hurricanes, and not all category 5
because some products didn't come right at that time so we
built it to the highest standards we could. All exposed
surfaces were built to withstand high impact wind and objects.
Our central energy plant provides 100 percent redundant power
for all utilities, potable water, sewage removal through
underground systems, and we have about 160,000 gallons of
diesel on-site underground.
The patient rooms were built for redundant medical gases
and electric. Our bed number can go, in the need of a surge,
our bed number for inpatients could go from 259 to 456 beds by
just simply bringing in more beds and equipment. Our emergency
center rooms can double from 27 patient exam rooms to be able
to take care of 54 due to the equipment size. Trauma rooms can
be increased from two to six. Our helipad can handle large and
multiple patient military size aircraft to remove patients or
bring patients as needed. As a trauma center, we maintain the
full slate of on-call subspecialists. The cost of this call
pay, other preparedness costs, are expected to exceed $6
million per year at our hospital. There is little funding for
many State or Federal agencies to help pay for these costs.
In relation to a couple questions that were asked earlier,
we did build permit decontamination stations into our building
that can handle 24 patients at a time for chemical and other
types of insult, and a 28-bed unit of ours can be converted to
total negative pressure capability in 10 minutes, therefore,
confining or quarantining patients and their contaminants in a
room rather than having them exposed to the rest of the
hospital. That ends my summary.
[The statement of Mr. Carnes follows:]
Prepared Statement of Gary A. Carnes
January 25, 2010
general comments
The comments contained herein generally apply to pediatric
hospitals and health care. However, the same issues, concepts, and
recommendations apply to adult health care.
Handling the human injury and illness results of disasters and
terrorist strikes does not and will not fall equally to all hospitals.
Key ``safety-net'' hospitals in each community will be called upon to
meet the initial patient surge demands. These facilities must be built,
prepared, equipped, and staffed differently. These specialized services
require specialized capabilities to be available 24 hours/day, every
day of the year. This is an extremely costly proposition for those
hospitals willing to make this part of their mission.
facilities
Most hospitals in the United States would not be able to
accommodate the facilities/physical plant needs for surge patients
resulting from a major disaster or terrorism strike. In fact, in the
case of a known and impending potential disaster (hurricane for
example) many facilities are looking to transfer critically ill and
fragile patients to hospitals better able to withstand the potential
insult.
The integrity of many facilities could be significantly compromised
by storms or a tornado, let alone a terrorist strike. Because of the
age of facilities, most hospitals are vulnerable. Just review the
effects of one storm--Hurricane Katrina.
A great lesson learned from Katrina was the fragility of public
utilities and the devastating effects upon hospitals when utilities are
disrupted. Most hospitals in the United States have only limited,
emergency power for critical systems and equipment. They cannot produce
potable water, move sewage, or maintain environmental control over
temperature and humidity. During Katrina, many hospital structures
remained well enough intact to provide care, but the building became
unsafe and ``sick'' due to loss of environmental integrity.
Generally, most hospitals cannot accommodate patient transfer by
helicopter. In the case of flooding or other surface disruption,
helicopter transport may be the only way to deliver or move patients.
Even in those hospitals where helicopter transport can be accommodated,
helipads are often on the roof and cannot handle the weight or rotor
span of large, multi-patient craft. This was a significant complicating
factor during Katrina. Moving patients one at a time by helicopter is
extremely inefficient, costly, and potentially dangerous.
Finally, very few hospitals maintain redundant equipment, supplies,
or materials on-site for disaster use. Extra space to adequately
accommodate patient influx is almost non-existent.
clinical considerations/requirements
The vast majority of hospitals in the United States simply cannot
adequately react to disasters or terrorist strikes that result in large
numbers of patients with significant injury, trauma, or illness.
The ``average'' emergency room is not equipped to accommodate a
significant surge. Generally, only certain hospitals (free-standing
children's, designated trauma centers, university/teaching) functioning
as true ``safety-net'' hospitals, have the capacity or available
clinical expertise to handle a surge of critically ill or injured
patients.
In addition to building and systems issues previously discussed,
the availability of medical and clinical personnel is also a
significant issue. The ``readiness cost'' just to have certain clinical
expertise on staff and available, before the first patient is ever
seen, can easily cost a hospital millions of dollars per year. Trauma,
general, orthopaedic, otolaryngologists, ophthalmologists, and
anesthesiologists must all be immediately available as surgical
specialties. Necessary medical specialists include internal medicine,
infectious disease, radiology, laboratory, pediatricians, and emergency
medicine.
Today, most all of the above specialists demand ``call pay'' to be
available. Additionally, hospitals must also assure the availability of
significant non-physician clinical (advanced nurse practitioners,
nurses, techs, etc.) and support staff to provide adequate response and
care. These readiness costs for a safety net hospital are staggering--
multiple millions of dollars per year.
the all children's hospital story
We recently opened a new 259-bed state-of-the-art quaternary
children's hospital and ambulatory building, supported by a complex
central energy plant, in St. Petersburg, Florida. The cost to construct
this facility was $403 million. We estimate the extra cost to upgrade
the facility to meet needed disaster preparedness and patient surge
requirements was at least $25 million. Documents showing improvements
we made are attached to this report, but a short list is:
Central Energy Plant and Fuel Tank Farm--100% redundancy to
maintain total environmental integrity and all utilities for at
least 2 weeks;
Upgraded helipad to facilitate large patient transport
craft;
Improved and storm-rated windows, protective walls, and
roofing;
Permanent decontamination stations;
Additional built-in medical gas and electric for surge
capabilities;
Redundant emergency communications.
Just to be a trauma center, our readiness (preparedness) costs
exceed $6 million per year. About one-half is paid as physician call
pay, and the other half for required additional staff, supplies, and
equipment. Very little Government financial support is received to
offset these costs. Maintaining trauma readiness is a key benefit to
accommodate patient surge due to a disaster or terrorist strike.
Specific surge capabilities, built into the new facilities to
accommodate patients from disasters and strikes, include:
Emergency Center equipped and sized to go from 27 to 54
patients;
Neonatal Intensive Care could be increased from 97 to 132
beds;
All other inpatient rooms could increase from 162 to 324
beds;
An entire 28-bed unit can be easily converted to negative
pressure, allowing the quarantine and control of infectious
patients;
Redundant warehouse storage to maintain and rotate supplies
and stores for disaster requirements.
These capabilities, as previously noted, were not inexpensive. But
as the only free-standing, quaternary, regional pediatric center on the
west coast of Florida, we felt these ``upgrades'' were necessary to
maintain services to the population.
We cannot move our patients during a disaster or terrorist strike--
no other facility can provide all the necessary clinical services. We
usually receive a minimum of forty (40) patient transfers to All
Children's when a storm is approaching. These are sent by other
facilities who fear they will not be able to provide the necessary
care.
We are fortunate to have been able to build our new hospital to
accommodate most surge capabilities. We are likely one of few hospitals
in the United States that can adequately meet these demands. Paying for
this ``readiness capability'' is expensive and an on-going struggle.
Mr. Carney. Thank you, and I thank everyone for their
testimony. Since I understand you are on a tight time frame,
Mr. Carnes, I will yield the first round of questions to my
good friend, Mr. Bilirakis.
Mr. Bilirakis. I would like to welcome the entire panel,
and I want to address my first round of questions to you, Mr.
Carnes. I know you have to catch a plane. All Children's
Hospital, everybody knows now, just completed a successful move
into a new state-of-the-art building. It is a fantastic
facility. If you ever come to Tampa Bay, please come and visit
us. A couple questions. What new capabilities will you have in
this new facility?
Mr. Carnes. From a clinical standpoint, not a lot of new
clinical programs because we were already providing certain
programs in a State that no one else even provided from a day-
in, day-out clinical programmatic area such as transplants and
things like that. But from emergency preparedness the fact that
we can stay as an island for 2 weeks or more due to the backup
redundant systems we have built makes us totally different than
currently any other hospital in Florida. So unless there is an
earthquake or a tornado rips the building apart or it is a bomb
or something like that, we can produce all water, electric,
move sewage. We can do everything that is needed.
We also built into the capability a redundant warehouse and
what we do is we move stores into the warehouse, bring them
into the hospital and replace those, so we have an on-going
rotation of stores, but it serves as an duplication of stores
and supplies on-site so that if needed we cannot take delivery
for quite some time and still maintain our ability to care for
patients. We also included in the building, we built an
interstitial floor so that there is no air handling equipment
or anything like that exposed to the environment. They are all
in the middle of the building on an enclosed fourth floor, so
they can't be reached by sunlight, wind, damage, those kinds of
things.
Mr. Bilirakis. You probably addressed this to a certain
extent but what unique challenges to treating children or other
special needs populations present during an emergency?
Mr. Carnes. For most hospitals, they don't have the variety
or sizes of equipment and supplies needed to take care of kids
everywhere from newborn up to adolescents, and that is probably
the biggest challenge that hospitals have is not the supplies
necessarily but also clinical expertise to recognize conditions
in children and then treat them properly.
Mr. Bilirakis. Very good. The H1N1 outbreak this fall
disproportionately impacted children, as everyone knows. What
impact did it have on operations at All Children's?
Mr. Carnes. We had about a 40 percent increase in emergency
room traffic for about 3 months, mostly related to H1N1. We
have to move one of our--we had to maintain our primary
emergency room, this was in the previous facility, for those
patients and moved to a secondary waiting room for other
patients, which really was part of our lobby. So in the new
building we have designed our emergency room with three or four
different waiting rooms, a main waiting room and then built
into it three or four separate sub-waiting rooms where we can
put patients of different types. As I mentioned, we can double
the amount of our emergency room capabilities simply by rolling
in more beds if we need to.
Mr. Bilirakis. Thank you, Mr. Chairman, I appreciate it.
Mr. Carney. Thank you, Mr. Bilirakis. Mr. Carnes, I think I
am asking this question on behalf of your Pennsylvania
colleagues. Certainly I am interested. What is the source of
your funding for that hospital?
Mr. Carnes. We put $200 million of our own cash into it and
we took debt for $200 million. We basically had no debt on our
old building so it was all new debt. Our old building was about
42 years old. We did receive for our helipad upgrade from FEMA,
we received three-quarters of a million dollars. That was the
delta between what our helipad would have cost us and the
oversized helipad. We also through HHS received $4.9 million, I
think it was, to make sure we had the most up-to-date
diagnostic equipment in the radiology suite that we wanted.
But we had already--also I--invested fully in a full
electronic medical record system. We have tele-medicine
capability to all our facilities on the west coast of Florida
and we have full picture archiving and transmission and receipt
of diagnostic images on that system too.
Mr. Carney. Very impressive. This question is for the
entire panel. In an effort to prepare for and medically respond
to a large-scale disaster, whatever it may be, man-made,
natural, whatever, there has got to be a true partnership
between the Federal Government, the State government, and the
local hospitals. From your perspective, for the whole panel,
does that relationship exist, and, if not, what do we need to
do? Dr. Skiendzieleski.
Dr. Skiendzielewski. I think you are correct. I think that
if something happens immediately I think our response is we
initially do the best with what we have and what we can. We try
to hold on, hold on till the cavalry arrives. I think over the
last several years the cavalry has come through for us.
Pennsylvania has certainly developed through our communications
network and through the local hospitals and through the caches
that we have available enabled us to hold on and go a little
beyond that. In the case of a significant even which would
exceed even those types of responses, I think FEMA then would
have to come in and take place. I am not exactly sure that I am
confident about that part of it.
Mr. Carney. Sure. Sure. Mike O'Keefe.
Mr. O'Keefe. Thank you. I think it is important that
representatives of various agencies need to meet and develop
relationships under non-stressful circumstances before they
need to meet and take action in a crisis situation. I think at
a local level, I think we are very fortunate. Evangelical
Hospital is located in the North Central Task Force region,
which includes I think seven counties and 11 hospitals. We are
very fortunate because of our unique geographical location, we
also have a mutual alignment with the east central, which would
be Geisinger Medical Center and Sunbury Hospital and like that
in our area. So I think at the local level we have good rapport
and a good relationship.
I think a concern that I would have would be complacency
between the State and the Federal level. I think it is
important that, as I mentioned, organizations and
representatives of different agencies, meet and develop
relationships so they will know who to call and what their
capabilities are again in non-stressful situations because
unfortunately a crisis situation is going to happen.
Mr. Carney. Next.
Mr. Kane. My answer is very similar. If you just look at
the agencies involved, you have got Joint Commission,
Department of Health, PEMA, FEMA, DHS, HHS, and CMS. These
agencies all have a different purview and regulations. If you
just take the regulations that we come under related to Joint
Commission and Department of Health, and they review us
regularly, their requirements are different, and there should
be some uniformity in this area.
Mr. Carney. That is interesting.
Mr. Carnes. We in Florida face every April 1 basically the
beginning of another hurricane season so we are pretty
accustomed to planning for and trying to come up with plans to
mitigate the problems of a disaster of that type. The States
has an active program in Florida. They have an annual
conference for disaster preparedness, and FEMA, I believe, does
send people to participate in that. But like the others there
is always that question about the alphabet soup of agencies and
whether they will all be coordinated. We saw a little problem
with that when the hurricane came through Homestead a few years
ago, and we certainly saw problems when Katrina went through
New Orleans. But I would say in our State we just, due to where
we are and what we face, we have probably a little closer
relationship with FEMA because they are in our State quite a
bit more maybe than they are other States.
Mr. Carney. Thank you. Mr. Bilirakis.
Mr. Bilirakis. I have a couple more questions for Mr.
Carnes. What lessons from the recent move can you use to
enhance your evacuation or other disaster plans?
Mr. Carnes. Well, I think we learned that nothing is as
easy as it looks sometimes, and that you need to be prepared
and even more prepared. We spent 2 years just planning to move
the patients on paper, doing mock moves, putting patients in
beds and moving them, kids of workers and things. We did that
many times, and I think that helped us during the day of the
move. That is the kind of thing that will help us if we ever
have to move patients, I think, during a storm, but we tried to
build in as many redundant and safety features into the
hospital as we could. It cost us at least a minimum of $25
million more to do that and probably more than 10 percent of
the cost of the hospital if we had counted for all the delta
between what we could have gotten by with and what we ended up
doing.
Mr. Bilirakis. Would you please share us the experiences
All Children's has had trying to access Federal funds for
increasing surge capabilities and making improvements to
respond to the community needs in general?
Mr. Carnes. Yes. As I mentioned, we did receive two grants,
one from FEMA for the helicopter pad, and one from HHS for some
diagnostic equipment. The issue we ran into, and it even kept
going through the stimulus funding, was that we began this
project, planning this project, more than 7 years ago, and it
took us about 3.5 years to build the project. Because we had
already put caissons in the ground, we hadn't built the
building yet or anything, but we had started to put the
foundation in, we were told we were ineligible for a lot of the
Federal funding to do some of the things we did simply because
we had already begun the project, and they did not approval
status over that project because it was already designed,
obligated, et cetera, et cetera, even though they told us that
they would have liked a lot of the things that we did. We
weren't eligible for the funding because the project had
already physically begun.
We were able to get the helicopter pad through your office
and Congressman Young's office and a few others because we had
not actually started construction on the helicopter pad at the
time so that is why we were able to get the little bit of money
from FEMA to help offset that additional cost.
Mr. Bilirakis. Thank you. For the entire panel, how
frequently does your hospital exercise its emergency response
plans?
Dr. Skiendzielewski. The Joint Commission requires us to
have our response, our disaster plans, at least once yearly
where we actually have casualties, mock casualties, enter the
hospital. In addition to that, we also will have drills on
other portions of our plant. We have a nuclear power plant
about 20 miles away, and every year we work on decontamination
with the nuclear power plant. We do mock weather disaster
drills. We will do mock infrastructure failure drills, and
these are all done at least annually. In addition, we will have
actual events which can occur. We mobilized our Incident
Command System last summer when we had a water leakage in one
of our pipes, so we look for opportunities in order to do that
in order to maintain our preparedness and our capabilities.
Mr. Bilirakis. Thank you. Dr. O'Keefe.
Mr. O'Keefe. I think most hospitals, as the doctor said,
almost on a daily basis go through exercises that can only be
replicated in a drill situation. We actually have better
response on a day-by-day basis than we do when we have drills
per se because people in the back of their mind they know it is
a drill. It is an exercise. At the same time all the emergency
departments seems to be ready in case that unfortunate bus
accident happens or in this part of the country if a loaded
buggy gets hit unfortunately we need to be able to handle
things like that. But really the drills, we do exercises in
concert with other area facilities on a regular basis
throughout the course of the year utilizing not only health
department but also local agencies as well.
One concern, if I could go back over here as well regarding
that, is our critical concern, is response reliability.
Unfortunately, it has been shown through Katrina that 50 to 80
percent of the responders sometimes health care workers will
not report if they are concerned about their families, their
immediate families may be in danger. So responders' support
must not be taken for granted or just assumed that it is
automatically going to be there. That is something we need to
work on and just keep in the forefront of our minds as well.
Mr. Bilirakis. Thank you.
Mr. Kane. At Susquehanna Health we have invested in a
coordinator of emergency preparedness that specifically focuses
full-time on drills and training. He is with us here in the
audience today. He was at Hurricane Gustav as part of our
response team. We drill multiple times a year. We have
something going on probably monthly. Probably most important in
our system is the fact that we have sent 40 individuals to
training at the Center for Domestic Preparedness in Aniston,
Alabama for the Incident Command Training, and that is a big
part of our process.
Mr. Carnes. We--as a trauma center, we are pretty much
ready 24 hours a day, 7 days a week, to take whatever happens.
As I mentioned, we have all needed subspecialties on call. We
have made some arrangements for some people to sleep in during
disasters so that we can keep staffing people, and we have set
our plan so that if you are there and come in, you are not
leaving until we can replace you so it is--and people sign up
for it. It is a known plan so we try to do that. In addition to
just being ready as a trauma center, we have at least two of
our home full drills a year of our emergency preparedness. The
county also has an all-hospital drill date at least once a year
and you get mock casualties from that. We never know what the
casualties will be until they get there.
Then as a hurricane State, we are almost always at least
once or more times a year call our plan into process just
simply because we don't know where a storm is going to go. With
our new emergency system, our central energy plant, we have
obligated ourselves to run that thing for a full day once a
month just to make sure that it is operating properly.
Mr. Bilirakis. Thank you. Thank you, Mr. Chairman.
Mr. Carney. This is primarily for the Pennsylvania
contingent. It is great to hear that each one of the hospitals
does the drilling, does the preparation for what is likely to
affect us, and thankfully we almost never deal with a
hurricane. We deal with remnants of hurricanes occasionally but
usually not the full force. Do you do this as individual
hospitals or do you work together in preparing for something
that might happen regionally? Susquehanna, do you talk to Evan,
and, Evan, you talk to Geisinger, and, Geisinger, do you talk
to Susquehanna and back and forth when you do these plannings?
Dr. Skiendzielewski. As I mentioned, we started doing this
30 years ago. We developed an inter-hospital plan including
Evan. It didn't extend quite up to Williamsport but it did
include Muncy Valley Hospital. We think that it is essential
when we plan to have communications, and the reason that we did
this plan in that way is because of resources that needed
perhaps to be shared. We needed to know where is the best place
to take patients, to accept patients, and that seems to work
out very well for us.
Mr. O'Keefe. I would echo that, and also we may not have
the hurricanes that Florida has, but Interstate 80 seems to be
a break point in weather. I remember a couple years ago there
was a massive wreck, series of wrecks up there, that I believe
all the hospitals in the area were called upon to react to, a
weak link or Achilles heel, if you will, through this. We do
also participate with the other area facilities on planning for
this, as well as trying to coordinate response. But a weak link
that may--and I can go back and emphasize what Dr.
Skiendzielewski mentioned is that the rural area, rural
situations, the emergency responders oftentimes are volunteers,
and that is very difficult to draw upon, I will say Monday
through Friday 9:00 to 5:00. Even sometimes nights and weekends
they can be bare bone as well, but that is an area of need to
somehow help shore that up.
Mr. Kane. I would add to what has been said with, yes, I
think there needs to be more planning communication between the
hospitals and the rural area. One of the recommendations we had
in our testimony was for the Federal or State support to
provide a way for hospitals to get together to do more
cooperative planning. There is plenty of planning code within
counties. There is planning amongst county providers. There is
county plans and so on. There is regional plans, but most of
those are focused between how the hospital deals with school
systems or counties or public of whatever, but as far as what
happens supporting each of the hospitals in the area, it is
mostly done by hospitals that are closer together. It should be
more regional.
Mr. Carney. Have you ever planned--I am sorry, Mr. Carnes.
I will get to you in a second. Have you ever planned between
the three of you and other hospitals, say Shamokin and Sunbury
and Muncy, as one event? Has that ever happened?
Mr. O'Keefe. Yes, we have.
Mr. Carney. How often do you do that?
Mr. O'Keefe. Probably not often enough compared to the
subcommittee here, but we have had mutual facility exercises
where we have even had observers in from the State level making
sure that those are coordinated events. For example, if it was
the Bureau of Prisons or if it was at the local nuclear power
plant, we have coordinated activities and exercises.
Dr. Skiendzielewski. Yeah, that was the whole premise of
that inter-hospital plan that everybody works together to make
it happen.
Mr. Carney. But you do exercise. It is one thing to plan.
It is a whole other thing to actually do it. I appreciate that.
Mr. Carnes, and I assume you have the same kind of relationship
with hospitals in your region?
Mr. Carnes. Yeah, as I said, our county does formal
planning, our region does formal planning and formal exercising
so twice a year in the county and once a year on a regional
basis we do formal exercises and get different patients in. We
just see what comes in during those, but, yeah, we do that in
Florida.
Mr. Carney. You have all mentioned, perhaps, and I hope it
is not, but it sounds like there might be an increasing
shortage in emergency medical technicians and first responders.
Is that your experience?
Dr. Skiendzielewski. Well, I don't know if they are not--if
they are decreasing, but again the rural area is just so much
different than the urban area, and what we find is our
volunteers now sometimes are working two jobs, and they just
don't have the time to do ahead and volunteer as much as they
would like. To compensate, a lot of our ambulance companies,
EMS services now, are hiring people so they do have to employ
some folks and then fill in with volunteers on shifts when they
still are able to do so. So it is changing a bit but I think
that we still have enough people that are interested I doing it
such that that is not a real issue for us although I am sure
that if we were able to assure the availability by having more
paid positions that would put us at better stead.
Mr. Carney. Is there any sense of the number of how short
we are in terms of responders? Do we have enough but we just
don't have it at the right times, we don't have enough?
Dr. Skiendzielewski. I don't have a real sense of that,
sir. I know that people in this area when somebody needs to go,
they go.
Mr. O'Keefe. One of the other compounding factors, it is a
back-handed compliment, is that the expectations, the training,
the regular annual updates that have to happen are becoming
more onerous. It is a good thing because the people that
respond are that much more skilled and better trained but it is
extra demands on their time when they are already busy people.
Mr. Kane. I can only respond to our area of Northeastern
Pennsylvania. I can't think of any volunteer fire company in
our area that wouldn't say there wasn't a serious staffing
shortage related to EMT personnel. It is a significant issue,
and as a hospital system, we become a staffing company
basically to provide staffing to those local ambulance
services.
Mr. Carnes. We are an urban area. There is really not a lot
of volunteer fire and other types of organizations. They are
mostly paid, and they do respond if they are required but
making sure they stay is another issue sometimes. Our bigger
issue for us is that, and this has to do just with pediatrics,
is the shortage and the impending real critical shortage of
pediatric specialty care people. There are only about 12
people, 12 people graduating from training program and
pediatric neurosurgery in the United States this year, about 12
in orthopedics, so if you look at spreading those across 50
States, 43 freestanding children's hospitals, and probably a
couple hundred other places that have some pediatric beds it is
a real problem. It is going to be a real problem for those in
the future as the population grows, and there are a variety of
bills before Congress to do some things about the training
programs and the universities, but for pediatrics it is a
significant problem in the future.
Mr. Carney. Thank you. Mr. Bilirakis.
Mr. Bilirakis. Thank you. This is for the entire panel, but
I know, Mr. Carnes, you have to leave. I don't want you to miss
your plane, so if you can address it first. What are the three
most important things that could be done to increase hospitals'
ability to surge? What assistance can be provided by the
Federal Government? This is your chance. Not simply in terms of
funding, but also in terms of personnel, guidance, or other
resources, what more could the Federal Government do to assist
you to enhance your medical surge capacity?
Mr. Carnes. Well, if you don't want to talk about funding
for buildings, people. I mean you have to have the people. No
matter how good of a building, you still have to have the
people in there, and for pediatrics there is a significant
shortage of those people, not just physicians but mid-level
practitioners, nurses, those kinds of people. There is just not
a lot of pediatric training for people done in their primary
education whether they are physician, nurse, or whatever they
might be. So additional training slots for a variety of
physician and non-physician for hospitals. The other is better
coordination, I would say, with different agencies and quick
strike response when there is a problem. We have built for the
inevitable that we would be alone 2 weeks. I don't think that
will ever happen just due to where we are and the assistance I
know we will get. But you have to--the government, whether it
is State, local, Federal needs an ability, I believe, to have a
quick strike response with food supplies, fuel, whatever might
be needed or to transfer patients from facilities that can't
make into facilities it can.
Even during a normal hurricane, we generally get 40 to 50
patients transferred to us long before the storm ever gets
there who are medically fragile patients in long-term care
facilities and things like that, so our sense is we will go up
40 to 50 even during any storm, and they get there in a variety
of ways, not all of them very good, sometimes just brought by
their families in a car because they are concerned, so those
things could be--if they were better planned and better
executed would help the patients and the response, I believe.
Mr. Bilirakis. Thank you.
Mr. Kane. I appreciate the question because I wasn't able
to answer and give my recommendations earlier. First of all, I
would say three. Financial support to stockpile medications and
equipment for mass casualty incidents and rapid delivery of
additional medical supplies is paramount. Two, I would say
rapid deployment of an Incident Management Team or liaisons to
hospitals in the initial hours of a disaster with the authority
to request additional Federal resources. Third, I would
probably say something that reinforces what I said earlier,
provide Federal templates for health care emergency operations
plans and mass casualty incident management to be adopted at
the State and local levels so we have some uniform templates.
Mr. Bilirakis. Thank you very much.
Mr. O'Keefe. I think Mr. Kane hit on some of the critical
components. Some of the things I would add to that would be
consistency of information technology, not only capabilities
but also the language that is necessary between institutions
and organizations. Likewise, even just communication
capabilities, as I pointed out, that is often the greatest need
but it is often the weakest link there as well, so I think
those would be additional pressing needs that need to be
addressed or could be better served.
Dr. Skiendzielewski. I think Mr. O'Keefe was looking at my
expressions here. ITF, I think, is huge. Working an emergency
department day-by-day, there is a tremendous amount of
redundancy that we have to accomplish when caring for
critically ill or injured patients. Folks get expensive tests
done at one hospital, and then they come to ours sometimes they
are repeated because their X-ray information just doesn't talk
to ours. I think that if we could find some way to universally
connect infrastructure, that would certainly help a great deal,
and it would help with the communications part of it as well.
Mr. Bilirakis. Thank you very much. I yield back the
balance.
Mr. Carney. In addition, I want to echo what you have all
said. I think we need real broadband in a big way through here.
I think that would facilitate all of this, and I know that is
something we are all focused on in Washington is getting that
done. I am not sure how to phrase this. I am kind of happy Mr.
Carnes has departed because he is from the urban area. Is there
a difference between urban and rural in terms of resourcing for
natural disasters or man-made disasters? Is there a difference
in the funding that comes and how it is looked at in terms of
need?
Dr. Skiendzielewski. Sure. I think that the two biggest
things that we are talking about when we talk about rural
versus urban is, first of all, the distances that are involved.
In Philadelphia where I grew up, there is a big hospital
probably 2 miles away from one another. Here, we have
situations of transport and terrain and weather. Our
helicopters are--the reason why we have five helicopters is to
overcome those obstacles. When you have a huge incident, and
maybe it is just a bus that turns over, nevertheless that is a
significant, significant issue for us in the rural area because
of the transport that is involved.
The second, again coming back to the capabilities of the
pre-hospital care providers that you have. One of the key
things that you have to do when there is a mass casualty
incident is to do triage. In order to do triage well, you have
to do triage on more or less a regular basis. One of the things
that our helicopters provide us with is real experience pre-
hospital care, medics, and nurses on the helicopter that can
get to the scene and do that. However, if it is bad weather, we
very well may be relying upon someone who has very little
experience or very little training in this crucially important
portion of our response.
I think in the urban areas, I think they see this quite
frequently and so that certainly is a difference. Then you have
your choice when you are in a city of which trauma center you
are going to go to. Are you going to go to Jeff, are you going
to go to Penn, are you going to go to Hahnemann? Well, you
know, here if you are making those choices, you are talking
about an hour's helicopter ride perhaps to go some place else.
So I think there are really vast differences.
Mr. Kane. I think Dr. Skiendzielewski said that very well.
I would add one of our recommendations was the National Phone
Banks information hotlines to assist overburdened hospital
staff during an incident. Rural hospitals will not have the
physical capability to handle the volumes of phone calls
associated with these types of events.
Mr. Carney. Does being in a rural area mean that you don't
get enough information, do you think, do you not get adequate
funding because it is urban versus rural? Is there any formula
that would make sense that would fit when we are talking about
Federal funding and State funding?
Mr. O'Keefe. We probably would need to have our chief
financial officers here because I think you are leading with
our chin as far as feeling as though it is rural versus urban,
and feeling as though in central Pennsylvania, speaking for
myself but I think my colleagues would agree, this is a lower
cost area to provide care, and, therefore, we also receive what
I am going to say is a disproportionate decrease or discount in
what we are funded.
Mr. Carney. Okay. For emergency preparedness for your
ability to respond.
Mr. O'Keefe. Across the board.
Mr. Carney. Okay. Dr. Skiendzielewski, do you want to add
to that? You are not going to touch that one? Okay. Mr. Kane,
you said that you would like more guidance on the Federal
Government? We don't have enough guidance for you? What sort of
guidance would you like to see?
Mr. Kane. Well, that is always a double-edged sword but
what I am specifically referring to is uniformity and in
templates and in how we approach emergency preparedness
planning and how we respond to it, what the requirements are,
how will we be inspected by different agencies that have
expectations of us. So it is guidance in coming up with
something that is equitable among all rural institutions and
that it is effective in helping us cooperate with each other.
Mr. Carney. There are a number, as you are aware, of
Federally prepared response criteria and plans out there. Are
they not helpful?
Mr. Kane. Not for the rural areas.
Mr. Carney. I see.
Mr. Kane. I think there is a big difference.
Mr. Carney. Okay. Mr. Bilirakis.
Mr. Bilirakis. Thank you. The outbreak of the pandemic flu
we have been experiencing has been seen as a test case by many
experts to demonstrate how well prepared we are for a large-
scale medical crisis. I have a couple questions here, and for
the entire panel. What lessons did you take away from the H1N1
pandemic this fall? Did it test your surge capacity? Did your
hospitals face overcrowding in a waiting room area or intensive
care units? Did your hospitals face staff shortages due to the
illness either of the personnel or their families? Whoever
would like to start first.
Mr. Kane. I guess I will lead off on that. As far as
additional volumes, we probably had an additional 25 percent
volume in the emergency department which translates to about 60
patients a day at that time which definitely stresses any rural
system. Some of the things that we learned, immediate education
for a lot of folks with flu-like symptoms to stay home rather
than coming to the hospital is important. We actually developed
a surge capacity area next to the emergency department as a
result of this so that we can easily provide more treatment
areas as needed.
The challenge in this is having enough provider staff
available during these events, and while there has been some
ease in how we credential additional staff to come in and do
that, there are still legal and liability implications about
bringing staff into an institution that aren't regularly
working there who are not employed by the institution so from
the State level we are allowed to bring in additional folks.
The question has not been answered yet related to the liability
of not doing an exhaustive screening of providers coming in to
a facility.
Mr. O'Keefe. Volumes in our emergency department during the
first or second wave did increase probably about 15 or 20
percent. Fortunately, not many of those resulted in admissions,
in patient admissions. We were able to actually care for most
of those people. Our concern is the communication that happens.
Unfortunately, sometimes the media can heighten some concerns,
and we want to make sure that the appropriateness of the words
that are delivered to the population are that they can
understand, wash your hands, stay at home, like that. We were
also able to make alternate site arrangements so that we could
segregate those individuals who thought they had some type of a
flu-like illness so that they were not congregated in the
emergency department main waiting room proper so we could try
to isolate them and begin appropriate care on an earlier basis.
Dr. Skiendzielewski. I think some of our experience echoes
some of the numbers that you have heard from Williamsport and
from the Evangelical Hospital as far as our increases in
patients seen. What I have learned from this was that in this
instance you can't put together a plan and then that is the
plan. As an emergency physician, we are used to being a little
shifty in trying to do things on the fly, and that is exactly
what we did with the flu in emergency medicine. Things would
change from day to day. There would be new directives out on
who to treat, who not to treat, should you do a test, should
you not do a test. You needed to basically apply those and do
updates every 24 hours.
Based on that, I think that helped us get through some of
the issues that we faced. I think the health system in general
did a great job as far as getting their employees vaccinated
and getting the patients in their--we have multiple primary
care sites through the region, and those folks were getting
their primary care patients vaccinated. The message went out.
If you have the flu and you are not in one of the high-risk
groups then probably you should stay home and take care of
yourself, and that message got out early very well.
We did not see any staff shortages, I think mainly because
90 percent of our folks got vaccinated, and the other 10
percent washed their hands all the time and wore masks. We made
the patients that came in and visitors that came into the
hospital all had to--if they had any signs or symptoms of flu,
they had to wear masks as well, so I think we did a great job
at mitigating the effects of this for ourselves.
Mr. O'Keefe. If I can, just one more quick comment about
that. I think because you can see it coming, we actually
participate, Evangelical along with Geisinger, Sunbury,
Bloomsburg hospitals, and the like, Bucknell University,
Susquehanna University, Bloomsburg University in coordinating
efforts planning for what can we do, so to your points about
preparation and anticipating some of this, I think some of
those actions ahead of time play off to the benefit of the
community at large.
Mr. Kane. We had a similar experience in our three
hospitals, the local, Lycoming College, Penn College and other
local facilities. We cooperated with each other on what we were
doing and what we were communicating. That was very important.
Mr. Bilirakis. Thank you. Yield back the balance. I don't
have any time left.
Mr. Carney. Yeah, there is always the possibility that we
will have some kind of mass casualty event in New York or
Philadelphia or even Tampa for that matter. Do you share
information back and forth of hospitals in those regions? Do
you exercise with them? Is there some kind of planning that
might go on in case they had to evacuate citizens or patients?
Dr. Skiendzielewski. The best we had was the FRED system
which is basically a Pennsylvania-based system. We don't
regularly do drills from that extent to Philadelphia and those
areas.
Mr. Carney. Outside the FRED system, which can be flawed at
times, I think it works decently but it can be flawed, have you
developed kind of those interpersonal relationships? Is there a
phone call? Is there somebody you can go talk to and say, look,
you know, this has happened. Can you take on 50 or however many
folks?
Dr. Skiendzielewski. I am not sure about 50, but certainly
we have personal contacts with folks in Philadelphia and
Pittsburgh and Allentown area, Scranton, their hospital in the
valley as well, and certainly we haven't been asked to do that,
but certainly if they were overwhelmed we certainly would
respond. The fact that we have the transportation capabilities
with our five helicopters puts us in a good position in order
to assist with that if we were asked to do so. We were put on
standby for 9/11. As a matter of fact, if we needed to respond
there we would have been able to go ahead or else backfill some
of the EMS facilities in New Jersey that went into New York. So
we are always ready to help in those instances.
Mr. Carney. So from that perspective God forbid another 9/
11 happened, are you all, I wouldn't say on the hook, but are
you all prepared or in some kind of chain to respond if there
are ripple effects this far west?
Dr. Skiendzielewski. I don't think that there is a formal
chain that has been developed but certainly we will be ready.
Mr. O'Keefe. I know that Evangelical Hospital had two of
our nine emergency room physicians just spent the last week in
Haiti along with five of the nursing staff, so not only is it
our own homeland that we are ready to respond to but as
necessary beyond as appropriate.
Mr. Kane. We also had emergency physicians from two of our
emergency departments that are in Haiti. We responded to
Gustav, as I mentioned earlier, and I do think there is
communication back and forth, but I think there could be a more
planned formal process of drilling with other institutions
further away.
Mr. Carney. Well, gentlemen, I want to thank you for your
time and your testimony. I think it is valuable to get the
perspective of the folks on the ground who could be impacted.
The challenges you face in the rural area certainly--there is a
lot of rural hospitals out there in this country, not just in
the tenth district of Pennsylvania certainly. Your perspectives
are most appreciated. If we have further questions, we will
contact you and I anticipate there will be further questions.
But with that, this subcommittee stands adjourned. Oh, excuse
me.
Mr. Bilirakis. I wanted to thank the city of Danville for
hosting us here today, and I want to thank our Chairman here
who--I know you hear a lot of horror stories of Washington, DC
about the lack of bipartisanship but it doesn't happen in this
subcommittee. We work together, and it should be that way all
over particularly with Homeland Security. I understand, Chris,
you are working on maybe having a hearing in Florida. I know
that is a great sacrifice during this time of year but we look
forward to you coming down. Thanks so much.
Mr. Carney. Thank you, Mr. Bilirakis. With that, the
subcommittee stands adjourned.
[Whereupon, at 1:50 p.m., the subcommittee was adjourned.]
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