Recommendations for Hospital Preparedness for Pandemic Influenza
By the Staff of the Center for Biosecurity, May 9, 2006
On March 1, 2006, the Center for Biosecurity convened a meeting to address the issue of U.S. hospital preparedness for pandemic influenza. In attendance were senior government officials, hospital leaders, clinicians, and public health officials from across the country, invited for the purpose of identifying solutions to the problems hospitals facing U.S. hospitals, which are not adequately prepared to respond to influenza pandemic. A full report of the meeting is available on the Center’s web site and will be published in the June issue of the journal Biosecurity and Bioterrorism.
Analysis by the Center for Biosecurity, with input from meeting attendees, identified the following 6 problems as fundamental barriers to adequate hospital pandemic preparedness:
Hospital “preparedness” has not been defined clearly
Several key preparedness tasks cannot be accomplished by hospitals acting individually
The demand for healthcare will exceed capacity.
A critical shortage of hospital workers will occur.
Federal funding for hospital preparedness is inadequate.
A severe pandemic may threaten hospitals’ solvency.
A potential solution was proposed for each of the challenges identified above:
1. Revise the hospital section of the Pandemic Influenza Plan issued by the U.S. Department of Health and Human Services (DHHS): With advice from hospitals, outside experts, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), DHHS should revise its pandemic plan for hospitals to define specific and nationally sanctioned preparedness goals, priorities, and metrics.
The revised plan should distinguish responsibilities of individual hospitals from regional responsibilities.
The revised plan should be aligned with existing Health Resources and Services Administration (HRSA) benchmarks and JCAHO standards.
2. Create regional hospital coordinating (RHoC) groups: Every community across the country should establish groups consisting of representatives of every general hospital in the area. The groups would have the following essential functions and duties:
Standardize planning and preparedness among the participating hospitals.
Expand the role of hospitals in traditional emergency operation centers.
Enable sharing of assets, staff, and patients among hospitals.
Share situational awareness in disasters among hospitals and between hospitals and other agencies.
Coordinate processes to support surge, which is the expansion of patient capacity within individual hospitals while retaining near normal practice standards, and super surge, which is the further expansion of patient capacity involving use of alternative care sites and/or significant alteration in practice standards.
Facilitate a community-wide approach to addressing ethical and political challenges, such as processes to implement altered standards of care during a severe pandemic.
Serve as an advisory body to public health and elected officials on medical issues.
Communicate with the public and the media.
Establish systems for jointly recruiting and coordinating volunteers.
3. Develop a framework for optimal allocation of limited medical resources: Groups at the national, regional and hospital levels should be created to develop a tiered framework of guidelines for decision-making. Each of these groups will have to consider the following issues: deferral of services, admission/discharge criteria, criteria for use of resource-intensive care, criteria for the alteration of practice standards, and delivery of care in “alternate care sites.” Composition and activity of these groups is described below:
National level: A blue ribbon panel of experts will develop consensus guidelines based on evidence, ethics, and the law; this panel will be appointed by the secretary of DHHS.
Regional level: Joint decision-making bodies will be charged with applying national the guidelines to local conditions.
Hospital level: Teams of senior clinicians will implement the guidelines as they apply to individual patients.
4. Use volunteers to maintain medical services: Local systems for volunteer enlistment, credentialing, and call-up should operate with greater efficiency and consistency.
There should be enhanced funding and development of the state-based Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP).
There should be uniform credentialing guidelines across states and nationally scoped liability protection during emergencies.
The many existing non-integrated local volunteer systems need to be organized to better accommodate non-professional volunteers. The Citizen Corps Council may provide a platform for such state-based registration and coordination.
5. Provide funding for hospital pandemic preparedness: DHHS should designate a working group to calculate more precisely the cost of hospital preparedness based on agreed upon planning assumptions. This is urgent.
Based on the conclusions of this group, an emergency supplemental Congressional appropriation should be made; the funds should be distributed to hospitals according to existing HRSA funding mechanisms, with some modifications.
HRSA should limit the amount that state health departments can retain for overhead.
Hospital funding should be tied to achievement of clearly defined goals based on metrics that should be built into the pandemic plans for hospitals, and there should be a mechanism for holding hospitals accountable.*
Regional planning should be funded through the RHoC groups.
6. Provide federal emergency financial aid to hospitals severely affected by a pandemic: DHHS should develop and Congress should fund a program to reimburse hospitals for uncompensated care and extraordinary costs resulting from a pandemic. This could be accomplished through amendment of the Stafford Act.
In addition, the government should provide loan guarantees to offset transient negative cash flow due to deferral of profitable elective services (with the presumption that the deferred services will be provided later).
Regardless of the mechanism for providing financial relief for hospitals, it is essential that the hospitals have advance notice of qualifications for reimbursement, e.g. the data collection requirements.
The Time to Act is Now
The heightening threat from H5N1 puts everyone at risk. Until there are sufficient supplies of effective vaccines and antivirals, hospital care of the sick is crucial to preparations for an influenza pandemic. Reductions in the numbers of hospital beds, over-crowded emergency departments, just-in-time supply chains, and staffing shortages have rendered U.S. hospitals less prepared now than 40 years ago to accommodate the predictable surge of critically ill patients.
The President and Congress are engaged on the issue of pandemic influenza, and there is widespread public and media interest. There is also legislation pending that could be used a vehicles to enact the proposals detailed above. Toward that end, these recommendations have been communicated to the White House, the Secretary of DHHS, the Director of the Centers for Disease Control (CDC), Congressional leaders, and senior staff from the congress and relevant agencies. There is wide agreement within the government that the lack of hospital preparedness is a critical vulnerability.
Those responsible for pandemic preparedness at the hospital level, particularly hospital CEOs and board members must become engaged as well. In the absence of major changes in the way that hospitals approach preparedness, they will fail in the event of a pandemic, and patients will die needlessly. As Secretary Leavitt has made abundantly clear, once a pandemic starts, the federal government cannot bail out communities that have failed to prepare.
Therefore, we call for an immediate governmental commitment to hospital preparedness proportional to the severity of the pandemic threat and for hospital leaders to acknowledge the existential threat a pandemic poses to their institutions and to act responsibly by greatly increasing their preparedness efforts.
*The Center for Biosecurity has estimated the initial cost of minimal hospital preparedness for a severe pandemic to be $5 billion, with an additional $500 million per year needed to maintain readiness.