Recommendations

Since the attacks of September 11, 2001 on the World Trade Center and the Pentagon, and the subsequent anthrax attacks, America’s collective psyche has suffered from the looming threats of terrorism and weapons of mass destruction/disruption, including the potential for the deliberate release of biological agents on civilian populations. Recent epidemics—and more recent re-occurrences—of severe acute respiratory syndrome (SARS) have been a reminder of the lethal and global effects of naturally occurring microbial pathogens.

Not the least of the unprecedented actions to protect the homeland have been efforts to improve the capabilities of hospitals and their clinical personnel to detect, monitor, treat, and contain disease outbreaks. In communities previously considered isolated and of little political value as targets of terrorism, America’s rural hospitals face this challenge with limited specialized clinical personnel and inadequate isolation facilities, personal protective equipment, and systems of communication to coordinate and integrate their actions with the external responder community. Rural America’s vital role in supporting our nation’s critical infrastructure, including agriculture, food production, and the National Highway System, disproves the pastoral notion of safety through seclusion.

Although this report focuses on the capabilities of rural hospitals to function under exacting conditions such as a mass casualty event, an infectious disease epidemic, or an act of bioterrorism, it illuminates the critical importance of a national homeland security framework that integrates all components of the response community to assure the health, safety, and protection of citizens and civil infrastructure. Aware of both the threat environment and the factors that increase vulnerabilities, the hospitals that participated in this study have revealed critical areas of deficiency and systemic fragmentation in preparedness efforts across communities, regions, and states that must be addressed. The following five recommendations are the most initially compelling; they require full and focused attention in the near term.

1. Develop a national consensus regarding the role of America’s rural hospitals in bioterrorism preparedness.

Recognition of the new threat environment has widened the horizons of rural hospital staff and expanded their responsibilities of. All hospital study participants acknowledged that rural hospitals are likely to play a future role in detecting or responding to a bioterrorist attack or an infectious disease epidemic involving a novel pathogen. Unfortunately, in many of these hospitals the relatively limited capacity, facilities, and infrastructure (e.g., security systems, communication systems, HVAC systems) are not designed to impede the spread of highly virulent or deliberately deployed infectious pathogens.

Rural hospitals play a primary care role for the communities they serve. Preparing for and responding to bioterrorism is a new responsibility and, to a large extent, remains an unfunded mandate. With the February 2004 release of Homeland Security Presidential Directive 9 (HSPD-9)—a call to arms for the United States agriculture and food system against terrorist attacks, major disasters, and other emergencies—rural vulnerabilities to terrorism have now been recognized at the highest levels of government. 72 Yet the President’s budget request for 2005 reflects a significant cut to hospital preparedness funding nationwide. 73

It is vital to the national homeland security strategy that we articulate the contributions rural hospitals may offer in response to a biological event and the demands that may be placed upon them, whether rural communities are directly targeted or indirectly affected. Preparedness strategies must emerge from a national dialogue and consensus among community leaders and experts in healthcare, defense, and other relevant sectors regarding the role of the rural hospital. A defined role and a nationally consistent, fully articulated construct for “minimal preparedness capacity” will guide efforts to train and equip rural hospitals for mass casualty biological events. Resources must be directed toward achieving specific preparedness goals that will allow rural hospitals to make realistic response contributions. Achievement of these goals should yield dual benefits, promoting the everyday business of rural hospitals as much as possible. Ideally, investments should improve rural health care while building preparedness.

2. Validate expectations of external assistance in the event of bioterrorism or a large-scale epidemic

Participants generally concluded that none of the hospitals were adequately designed, equipped or prepared to respond to and control highly communicable and potentially fatal infectious disease outbreaks, especially those deliberately deployed. Representatives at each of the hospitals acknowledged that outside expertise and extra staff would be required before expanding the hospital’s responsibilities in disease control and containment efforts. They also stated their expectations that communicable patients would be expeditiously transported offsite to a specialized and tertiary care facility, leaving behind a stable and otherwise functioning rural hospital to handle the routine provision of medical services.

An exploration of the realities and capabilities of rural hospitals through the lens of this study demonstrated that many rural hospitals are not easily accessible, especially during the winter months. The rapid insertion of expertise may well be hampered for a variety of logistical and other factors. Conversely, transport from a rural hospital to a tertiary care facility may contribute to the survivability of the index case and other acutely ill patients, but will not necessarily relieve or ameliorate the ongoing burden of the rural hospital in its attempts to evaluate patients and implement medical countermeasures for others who may have been exposed. The transport of contagious patients from the rural hospital may be slow, and expose patients and staff to disease in an environment of limited negative pressure isolation facilities and personal protective equipment.

Participants at each hospital listed a number of responder groups who they believed would assist them in the case of a health emergency, including the state public health department, the military, the sheriff’s office, and Border Patrol. Discussions with representatives of these groups, however, revealed that while they would attempt to provide some level of assistance, their primary responsibilities would restrict their support to hospitals.

Hospitals’ expectations of the source, scope, and timing of any external assistance are generally untested and, in some cases, unrealistic. For example, state public health departments acknowledged that their limited staffing, as well as the potential for multiple demands for assistance in the event of simultaneous attacks or outbreaks, would severely reduce their capacity to provide hands-on relief to rural hospitals. Furthermore, state public health departments are also on a steep learning curve, refining their knowledge base and the operational skills necessary to address bioterrorism. Nearby military installations may be repositories of expertise, but in the event of an attack their primary mission will be warfighting.

Communities must formalize roles and responsibilities that are realistic and operational in the event of bioterrorism or a mass casualty situation. Additionally, these relationships must be practiced through drills and simulations to ensure that diverse response sectors can work within an incident command structure.

3. Engage all sectors in integrating community-based planning and response efforts.

An outbreak of a contagious disease will impact the local community before spreading to distant locales. Many preparedness experts have acknowledged that the local community will be on its own for the first hours, if not days, of an attack or a serious disease outbreak. The quality of response during this initial window of time can make the difference between mitigating the spread of disease and allowing the progression of a far-reaching epidemic.

Despite the oft-noted axiom that “all response is local,” efforts at building local or regional capabilities remain disjointed, at best. Most streams of preparedness funding are sector-specific (e.g. specific streams of funds to police departments, fire and EMS, public health, and hospitals) rather than community-centric. This method of distributing funds fails to incentivize coordination, dilutes opportunities to merge expertise, and impairs efforts to capitalize upon the gains in resource elasticity accruable from increased workforce and equipment. Moreover, current sector-specific preparedness planning and activities have produced little interoperability of human and technical resources, rendering the job of supplementing hospitals and communities during a time of crisis problematic.

Perhaps the most glaring and pervasive fault line articulated by study participants is the persistent lack of integration in preparedness efforts across all response sectors including various levels of government, police and sheriff, EMS and safety, and public health. All respondents indicated strong commitments to their terrorism preparedness initiatives, but also recognized the necessity of a cohesive, cross-sector, and systemic response to effectively and efficiently parse out limited human and technical resources.

It is critical that we connect the funding and planning efforts across communities rather than in stovepipes within each sector. This will enable communities to integrate resources effectively and to build interoperable and expandable human and technical capabilities. The benefits of multi-sector collaboration and integrated capabilities are great, but they require a high level of joint effort to overcome the political and administrative hurdles within communities. Rather than a top-down approach, preparedness planning should be conceptualized, funded, and sustained by considerations from the bottom—or local level—up. Attention must be given to the requirements and capabilities necessary to protect populations and restore civil structures in the event of deliberate destruction/disruption.

4. Expand training and improve the understanding of biological threats.

Study discussions reveal that biological threats remain the least understood of the range of potential disasters and weapons of mass destruction/disruption. Biological attacks develop in fundamentally different ways than chemical, radiological, or explosive incidents—they can occur covertly, clinical settings may be the first lines of detection and response, and they are capable of spreading throughout populations until contained. Strong leadership guided by public health and medical expertise are required to requisition, direct, and commandeer appropriate resources. More robust and current education and training in biological disease events must be made available to the health care delivery sectors and their community responder colleagues.

Participants unanimously agreed that the lack of an adequate model for local bioterrorism preparedness training is a significant shortfall. Many noted that acquiring such training remains one of the most pressing preparedness challenges facing rural communities, particularly because of its cost and the inability of staff to leave their job responsibilities during the work day.

Because funding and a shortage of personnel restrict off-site educational venues, it is incumbent upon federal agencies to develop community-based preparedness training modules that can be given locally. Additionally, by exploiting the dual-benefit, bi-directional capabilities of telemedicine systems (several of the rural hospitals that participated in this study have these systems in place for conferences and for physician oversight of nurse practitioners), distance education can be an additional interactive vector for education and training.

5. Install a reliable and interoperable rural communications platform.

The diversity and lack of interoperability among communication systems in many rural responder communities would restrict the effective integration of medical and non-medical personnel in responding to a bioterrorist attack or any other mass casualty event. The Federal Communications Commission (FCC) and the National Telecommunications & Information Administration (NTIA) were directed by Congress in the 1990s to work together to resolve incompatibilities among federal, state, and local public safety radio equipment and spectrum usage. In response to this directive, NTIA issued a mandate to all federal agencies to conform their radio systems to narrowband digital technologies (25 kHz), then considered more spectrally efficient, by no later than 2008. Subsequent narrowband technologies have narrowed this bandwidth down to as low as 6.25 kHz, but movement to the lower bandwidth is still not uniformly approved. Correspondingly, the FCC in its Fifth Report and Order of July 2002 legislated that new radio systems in the public safety band (700 MHz) will have to comply with the even more stringent 6.25 kHz channel bandwidth after December 31, 2006. However, since the FCC did not mandate that state and local responders move to the narrowband systems, the state and local responder communities—for economic reasons—were not required to conform their existing systems. 74

Throughout the 1990s, the communications industry has worked toward a solution to this problem. Recognizing the need for common standards for responders, representatives from the Association of Public Safety Communications Officials International (APCO), the National Association of State Telecommunications Directors (NASTD), selected federal agencies, and the National Communications System (NCS) established Project 25, a steering committee charged with selecting voluntary standards for interoperable digital public safety radio communications systems. Systems compliant with standards set by Project 25 have been increasingly adopted and deployed in responder communities. 75

The existing patchwork of old and new radio systems (based on local funding) restricts community interoperation. Challenges posed by mountainous terrain and extreme weather conditions require sophisticated redundancies and the consideration of technologies not yet deployed at the local level. (Satellite telephones may be viable and should be considered as backups, where appropriate.) Local, state, and federal responder communities should be required to provide at least a minimal number of totally compatible systems and funding provided for procurement. State, local, and federal responder communities must focus more attention on building a real-time emergency communications system that fully meets interoperability conditions across medical, responder, and government sectors and within organizations. 76 The Department of Homeland Security, with input from the states, must coordinate and mandate a minimal set of responder communications standards and guidelines. Current threats and vulnerabilities necessitate concerted efforts to solve the critical rural communications problems presented by system mismatches and geographical isolation.

72. See http://www.whitehouse.gov/news/releases/2004/02/20040203-2.html. Accessed April 2004.
73. See http://democrats.senate.gov/dpc/dpc-doc.cfm?doc_name=fs-108-2-32. Accessed April 2004.
74. Discussion with Frank E. Ferrante, President, FEF Group, LLC.
75. Telecommunications Industry Association (TIA) Online, “Project 25 (P25): Standards For Public Safety Radio Communications.” http://www.tiaonline.org/standards/project_25/.
76. Note the Universal Service Fund (USF) established by the Telecommunications Act of 1996 and overseen by the Federal Communications Commission requiring telecommunications companies in the U.S. to pay a portion of their revenues from customers into a fund which can be accessed by not-for-profit rural heath care organizations to finance communication development.