Summary and Conclusions

Five rural hospitals were selected to participate in a study of bioterrorism preparedness. Senior hospital administrators, clinical and managerial staff, elected community leadership, and representatives from law enforcement, public safety, and public health participated in guided discussions during two days at each site. Discussions focused on the challenges rural hospitals and their communities are encountering in addressing the threat of disease epidemics resulting from deliberately released or naturally emerging infectious pathogens. Although findings are not intended to represent the circumstances and opinions of all the country’s rural hospitals, the experiences and concerns of these five hospitals may contribute useful insights to national hospital preparedness efforts—both urban and rural.

Despite the unique qualities and vast distances separating the participating hospitals, the information shared and issues reported yielded strikingly similar concerns. All participants demonstrated a keen grasp of their hospital’s vulnerabilities within the context of the national threat environment. In recognizing their community’s status as a potentially attractive target, some participants had considered the possibility of being within the epicenter of a focused attack. Others suggested the potential for infection and contamination through inadvertent patient “downloads” from other hospitals, or other indirect, yet nonetheless compromising, scenarios. All study participants recounted efforts to initiate new policies and pursue training opportunities to improve their response capacities, skills, and understanding of pathogens and threat agents. Most noted that some progress has been made, particularly in terms of heightening their sensitivity to unusual events and in acknowledging the steep learning curve ahead.

All hospital study participants attributed their limited progress in achieving specifically improved preparedness capacities to the fact that promised funding had not yet arrived. The CEO of one of the largest hospitals noted, “Everyday I read about resources coming. [I] have not seen one dime. [We] have not had one training session. Where is that money going? Because none of it is coming here. It’s going to the big cities. …We have filled out endless documents and lists of resources and requests for equipment.” Other hospital administrators made similar comments, suggesting that homeland security-related funding for hospitals has yet to reach the local level.

The deliberate release of most Class A biological agents, or a naturally occurring outbreak of a disease such as SARS, will require timely, expert, and sustained response to halt the person-to-person chain of transmission. Rural hospitals have minimal staff, which necessitates that “everyone wears multiple hats.” There are no large reserves of staff within hospitals or their communities?few of those interviewed were able to identify nurse pools or other sources of trained personnel that could provide surge capacity within their area. Most of the hospitals that participated in this study have insufficient emergency department personnel and limited experience handling large-scale, mass-casualty events. Furthermore, training to address new threats is limited by the direct costs of tuition and offsite travel and the indirect costs associated with temporarily relieving staff from critical nursing and other duties. Augmenting local hospital response capacity through collaborative hospital efforts across geographic regions has been acknowledged as important to addressing the large demand for medical care during a biological event. Skills and procedures are not yet sufficiently interoperable to enable seamless and efficient operation when staff are deployed from one hospital to another during an emergency. Hospital consortia have begun to develop and articulate consensus-driven response strategies that might contribute to the implementation of regional response systems.

Human resource limitations are not unique to the hospital sector. Study participants from traditional responder agencies—law enforcement, fire and HAZMAT, and others—acknowledged that their sparse workforce would constrain the timeliness and sustainability of their response to a biological incident. Although these agencies also have engaged in efforts to improve preparedness through training, expanding skill sets, and augmenting stores of equipment, there are no large reserves of personnel to handle their own responsibilities during a long attack, let alone to divert staff to supplement and protect hospital resources. Furthermore, efforts to formalize arrangements for mutual aid with neighboring towns—often practical for traditional emergencies like multi-alarm fires—may be less successful in the context of terrorism and the potential exposure to weapons of mass destruction/disruption.

The level of networking and planning across the hospital and traditional responder communities—the sheriff’s office, the fire department, and others—has increased to address possible threats of terrorism, especially bioterrorism. However, these collaborative efforts have lacked both the resources and the technical guidance to build the cross-sector linkages required to contravene or mitigate the potentially devastating and unremitting sequelae of a biological attack or large-scale disease outbreak. Beyond the need to identify sufficient “expandable” resources across a community or within a region is the daunting effort to integrate these diversely trained personnel into a coherently functioning unit. As one hospital CEO succinctly expressed, “[There are] lots of different agencies and organizations but it is extremely difficult to understand how they all come together.”

Although the threat of a terrorist attack on a nuclear facility has become a more prominent concern in the post-9/11 climate, many rural hospitals have co-existed with nearby nuclear power facilities for decades. Hospitals also are familiar with responding to chemical spills and other situations requiring HAZMAT capabilities. As compared to other possible weapons of mass destruction/disruption, biological agents present the most difficult challenges to rural communities. The requirements of early clinical detection, swift and effective disease containment, and the protection of hospital personnel and patients are especially overwhelming in relatively close-knit communities where hospitals were “never built to be secure—just friendly.” Respondents at each of the participating hospitals thought they would not detect a large-scale biological event until much too late, at which point they would not be able to adequately protect the hospital staff or patients from exposure and infection. Many rural hospitals operate within a health care environment that lacks adequate negative-pressure isolation capabilities, patient cohorting strategies, and dedicated security personnel. The rural hospitals and pre-hospital providers (including EMTs) who participated in this study spoke of their limited training and the need for personal protective equipment (PPE). One fire department official noted that “[We] can wear the same turnout gear for years. But what about bio? Who’s going to pay for the PPE?”

Most participants recognized the importance of responding to a large-scale event within the rubric of well-defined leadership, expert skill sets, and practiced incident command. Unfortunately, many pre-existing response strategies still call for law enforcement or other medically unqualified personnel to assume the lead within the community during a biological event. A critical biological incident of any kind will necessitate proficient medical staff soon after the incident.

Most hospitals and their community partners recognize that outside assistance will be critical in the event of bioterrorism or a mass casualty situation. Some hospitals operate under the belief that rapid and expert assistance could be expected from a nearby military facility or a state public health department. Yet conflicting priorities, untested response paradigms, and the potential for multiple, simultaneous demands for this expertise may well leave the hospitals to their own limited resources. One local government official noted, “[I] have no more resources than I have had for years…. We have to have backup. Where will that come from? I can’t call the National Guard because they’re in Iraq. I can’t depend on the Highway Patrol—it takes them hours to get to a [car] wreck.” Some of the hospitals have attempted to improve their self-sufficiency by increasing supplies of pharmaceuticals, food, fuel, and, in one instance, potable water. However, most hospital administrators recognize that the nature of a biological event would challenge the basic capabilities of the average rural hospital. One hospital CEO noted, “In a rural setting, we have always believed we are on our own. But this—bioterrorism—we can’t do by ourselves.”

In the event of the release of a biological agent or a naturally occurring disease outbreak, swift containment and control of infection transmission is critically dependent upon the integrated efforts of the hospital and the pre-hospital and responder communities. On occasion, diverting potentially infected and contagious patients from a hospital may be necessary to avert contamination and preserve acute medical care capabilities. This scenario will require clear and consistent channels of communication between the hospital and pre-hospital providers (e.g., EMTs) in the field. According to all study participants, the communication technologies currently supporting rural communities are not commensurate with the responsibilities of the rural hospital in the event of bioterrorism, a non-deliberate disease epidemic, or any other mass-casualty incident Inadequacies in rural communication capabilities clearly are the result of a wide range of problems, including limited range of transmission and cellular infrastructure, signal interference due to geography and terrain, lack of interoperability of communication equipment across local, state and federal sectors, radio frequency saturation from simultaneous civilian and responder use during peak demand periods, and incompatibility of multiple hardware platforms (repeaters, switches). One county official noted, “I have a cell phone in my pocket but I can’t talk with my office one mile away.”

Additionally, communication strategies between the hospital and the community are critical to conserving limited hospital resources. Most participants spoke of their inability to alert the community to a health hazard or meter the flow of people who require the administration of pre- or post-exposure vaccines or other medical countermeasures. One hospital CEO noted, “If you bring disease and panic into a small community, we can spread it widely in a matter of hours. There is a lack of communication and education strategies to keep people safe and contained until appropriate equipment and personnel are brought in.” The very strength of the rural hospital—its friendly, open-door policy and designation as the community’s principal medical care provider—is simultaneously its Achilles’ heel. Multiple, unlocked entrances allow for the introduction of infections. The camaraderie and familiarity of hospital staff may prevent incorporation of the most rigorous and immediate of disease control methods (personal protective equipment, pre-hospital triage for respiratory symptoms, etc).

The plight of the rural hospital has not gone unnoticed by the public health sector. The role of the medical care delivery system is integral to the public health sector’s mission of protecting populations and applying epidemiologic skills to characterize and monitor disease outbreaks. With that in mind, state public health departments, supported by federal CDC and HRSA funds, are engaged in building preparedness plans that address the rural community. Unfortunately, this study demonstrates on multiple occasions that planning remains in a development phase, and that many of the existing public health communication problems have created barriers to preparedness. Furthermore, several of the site visits revealed that state preparedness planning has not always been apparent to local officials. First responders were often unaware of the scope of preparedness planning taking place at the state level.

America’s rural communities are frequently a portal to its larger, more populated urban areas. One hospital CEO’s comment summarized the precarious state of affairs of the rural hospital: “We are as vulnerable and as important to the safety of the nation, but we don’t have the financial wherewithal to protect the big cities if the entry point is here.”