Healthcare coalitions: the new foundation for national healthcare preparedness and response for catastrophic health emergencies.

After 9/11 and the 2001 anthrax letters, it was evident that our nation's healthcare system was largely underprepared to handle the unique needs and large volumes of people who would seek medical care following catastrophic health events. In response, in 2002 Congress established the Hospital Preparedness Program (HPP) in the U.S. Department of Health and Human Services (HHS) to strengthen the ability of U.S. hospitals to prepare for and respond to bioterrorism and naturally occurring epidemics and disasters. Since 2002, the program has resulted in substantial improvements in individual hospitals' disaster readiness. In 2007, the HHS Office of the Assistant Secretary for Preparedness and Response (ASPR) contracted with the Center for Biosecurity of the University of Pittsburgh Medical Center to conduct an assessment of U.S. hospital preparedness and to develop tools and recommendations for evaluating and improving future hospital preparedness efforts. One of the most important findings from this work is that healthcare coalitions-collaborative groups of local healthcare institutions and response agencies that work together to prepare for and respond to emergencies-have emerged throughout the U.S. since the HPP began. This article provides an overview of the HPP and the Center's hospital preparedness research for ASPR. Based on that work, the article also defines healthcare coalitions and identifies their structure and core functions, provides examples of more developed coalitions and common challenges faced by coalitions, and proposes that healthcare coalitions should become the foundation of a national strategy for healthcare preparedness and response for catastrophic health events.

The national disaster medical system: past, present, and suggestions for the future.

This article reviews the history and structure of the National Disaster Medical System (NDMS), with an emphasis on its definitive care component. NDMS's capacity to handle very large mass casualty events, such as those included in the National Planning Scenarios, is examined. Following Hurricane Katrina, Congress called for a reevaluation of NDMS. In that context, we make three key suggestions to improve NDMS's capacity to respond to large mass casualty disasters: (1) increase the level of engagement by the private (i.e., nonfederal) healthcare system in preparedness and response efforts; (2) increase the reliance on regional hospital collaborative networks as part of the backbone of the NDMS system; and (3) develop additional, alternative patient transportation systems, linked to the overall NDMS patient tracking effort, to decrease the sole reliance on DoD long-haul air transport in medical evacuation.

Challenges to global surveillance and response to infectious disease outbreaks of international importance.

This article presents a notional scheme of global surveillance and response to infectious disease outbreaks and reviews 14 international surveillance and response programs. In combination, the scheme and the programs illustrate how, in an ideal world and in the real world, infectious disease outbreaks of public health significance could be detected and contained. Notable practices and achievements of the programs are cited; these may be useful when instituting new programs or redesigning existing ones. Insufficiencies are identified in four critical areas: health infrastructure; scientific methods and concepts of operation; essential human, technical, and financial resources; and international policies. These insufficiencies challenge global surveillance of and response to infectious disease outbreaks of international importance. This article is intended to help policymakers appreciate the complexity of the problem and assess the impact and cost-effectiveness of proposed solutions. An assessment of the potential contribution of appropriate diagnostic tests to surveillance and response is included.

Regional approaches to hospital preparedness.

This article describes issues related to the engagement of hospitals and other community partners in a coordinated regional healthcare preparedness and response effort. The report is based on interviews with public health and hospital representatives from 13 regions or states across the country. It aims to identify key ingredients for building successful regional partnerships for healthcare preparedness as well as critical challenges and policy and practical recommendations for their development and sustainability.

Systemic collapse: Medical care in the aftermath of Hurricane Katrina.

This article describes and analyzes key aspects of the medical response to Hurricane Katrina in New Orleans. It is based on interviews with individuals involved in the response and on analysis of published reports and news articles. Findings include: (1) federal, state, and local disaster plans did not include provisions for keeping hospitals functioning during a large-scale emergency; (2) the National Disaster Medical System (NDMS) was ill-prepared for providing medical care to patients who needed it; (3) there was no coordinated system for recruiting, deploying, and managing volunteers; and (4) many Gulf Coast residents were separated from their medical records. The article makes recommendations for improvement.

Comments from the Center for Biosecurity of UPMC on proposed revisions to federal quarantine rules.

On November 30, 2005, the U.S. Centers for Disease Control and Prevention (CDC) proposed changes to federal quarantine regulations (42 CFR Parts 70 and 71). As stated in the proposed rules, the intent of changes is "to clarify and strengthen existing procedures to enable CDC to respond more effectively to current and potential communicable disease threats." Parts 70 and 71 of 42 CFR authorize the Secretary of the Department of Health and Human Services (HHS) to make and enforce regulations "as in his judgement are necessary to prevent the introduction, transmission, and spread of communicable diseases" from foreign countries (Part 71) and between states (Part 70). The Center for Biosecurity of UPMC reviewed the proposed revisions to the quarantine regulations and submitted to CDC the following analysis as its official comments on the revised rules.

Improving performance of HVAC systems to reduce exposure to aerosolized infectious agents in buildings; recommendations to reduce risks posed by biological attacks.

The prospect of biological attacks is a growing strategic threat. Covert aerosol attacks inside a building are of particular concern. In the summer of 2005, the Center for Biosecurity of the University of Pittsburgh Medical Center convened a Working Group to determine what steps could be taken to reduce the risk of exposure of building occupants after an aerosol release of a biological weapon. The Working Group was composed of subject matter experts in air filtration, building ventilation and pressurization, air conditioning and air distribution, biosecurity, building design and operation, building decontamination and restoration, economics, medicine, public health, and public policy. The group focused on functions of the heating, ventilation, and air conditioning systems in commercial or public buildings that could reduce the risk of exposure to deleterious aerosols following biological attacks. The Working Group's recommendations for building owners are based on the use of currently available, off-the-shelf technologies. These recommendations are modest in expense and could be implemented immediately. It is also the Working Group's judgment that the commitment and stewardship of a lead government agency is essential to secure the necessary financial and human resources and to plan and build a comprehensive, effective program to reduce exposure to aerosolized infectious agents in buildings.

Disease mitigation measures in the control of pandemic influenza.

The threat of an influenza pandemic has alarmed countries around the globe and given rise to an intense interest in disease mitigation measures. This article reviews what is known about the effectiveness and practical feasibility of a range of actions that might be taken in attempts to lessen the number of cases and deaths resulting from an influenza pandemic. The article also discusses potential adverse second- and third-order effects of mitigation actions that decision makers must take into account. Finally, the article summarizes the authors' judgments of the likely effectiveness and likely adverse consequences of the range of disease mitigation measures and suggests priorities and practical actions to be taken.

The prospect of using alternative medical care facilities in an influenza pandemic.

Alternative care facilities (ACFs) have been widely proposed in state, local, and national pandemic preparedness plans as a way to address the expected shortage of available medical facilities during an influenza pandemic. These plans describe many types of ACFs, but their function and roles are unclear and need to be carefully considered because of the limited resources available and the reduced treatment options likely to be provided in a pandemic. Federal and state pandemic plans and the medical literature were reviewed, and models for ACFs being considered were defined and categorized. Applicability of these models to an influenza pandemic was analyzed, and recommendations are offered for future ACF use. ACFs may be best suited to function as primary triage sites, providing limited supportive care, offering alternative isolation locations to influenza patients, and serving as recovery clinics to assist in expediting the discharge of patients from hospitals.