During the last decade, the United States confronted a range of infectious disease challenges, including SARS-CoV-2/COVID-19, H1N1 pandemic influenza, Middle Eastern Respiratory Syndrome (MERS), Ebola virus, and Zika virus. The United States government took steps to address these emerging risks through the development and implementation of policies such as the National Pandemic Influenza Plan,1 and the Centers for Medicare and Medicaid Services (CMS) emergency preparedness rule.2 Since the enactment of the CMS emergency preparedness rule, hospitals and public health systems in the U.S. have had to confront challenges involving outbreaks of measles,Reference Johnson3 Hepatitis A,4 a severe 2017-2018 flu season,5 and the recent outbreak of the COVID-19 novel coronavirus.6 An enduring challenge in the area of infectious disease preparedness and response is effective communication between health care and hospital systems, health care coalitions, emergency medical services, and public health agencies at the local and state levels in regard to surveillance and response. In this commentary, we briefly review the on-going risk to the United States posed by infectious disease. We then look at the current strategies to prepare for and combat infectious disease outbreaks and their gaps, with a particular focus on the issue of information sharing. This issue is of particular interest because of the gap between the technology available to facilitate information sharing and the challenges that organizations continue to face when carrying out the activity. The Public Health Emergency Preparedness (PHEP) program and the Hospital Preparedness Program (HPP), acting in coordination, are currently the best programs available for addressing these concerns. In the text of the 2017-2022 PHEP and HPP cooperative agreement, the third domain, of six, is strengthening information management. This domain includes enhancing communication between the medical and public health sectors, across disciplines, jurisdictions, and health sectors, and with the public. The activities under this domain include sharing situational awareness between the medical and public health sectors to create a common operating picture, sharing emergency information and warnings across disciplines, jurisdictions, and health care coalitions, and conducting external communication with the public.7
The capabilities of the HPP program include Activity 9: Enhance Infectious Disease Preparedness and Surge Response. There is some discussion of information sharing included with that activity, such as indicating that health care organizations should make sure to document patients’ exposure to infectious disease in electronic health records and making sure the information is provided to the case team and to state and local health departments. Health care coalitions are also supposed to “provide real-time information through coordinated HCC and jurisdictional public health information sharing systems.”8 The latter element is what should receive stronger focus moving forward to facilitate better surveillance and coordination.
The HPP and other programs have been hampered by inadequate funding,Reference Watson, Watson, Gastfriend and KirkSell9and an approach to hazard vulnerability analysis that favors higher probability but lowers consequence eventsReference Mamuji and Etkin10 (although the COVID-19 emergency may change that policy focus). This commentary summarizes recommendations for improvement advanced by organizations who have studied the issue and finally, we propose our own recommendation.
Continuing Threat Posed by Infectious Disease in the United States
While focus on Disease XReference Scutti11 has shed light upon the need to prepare for emergencies, outbreaks of emerging infectious diseases and seasonal influenza have raised concerns regarding the existing capacity for the United States health care system to adequately respond to biological incidents. Outbreak management and patient care in response to high-consequence infectious diseases can also be costly for the United States health care system, as the estimated cost of care for two patients is said to be roughly $1 million.Reference Herstein, Paul and Colleen12 Previous outbreaks, like SARS-CoV in Toronto and MERS-CoV in South Korea, have shed light on hospitals acting as amplifiers for disease and a critical need for health care to incorporate bio-preparedness efforts. Within the United States, outbreaks of drug-resistant organisms and the 2014 Ebola cluster in Dallas, Texas, indicate similar gaps in infectious disease preparedness and readiness.
Infectious disease is discussed in the domain of strengthening information sharing in the PHEP-HPP cooperative agreement. The agreement advises that health care coalitions, in an effort to coordinate PHEP and HPP awardees and other stakeholders, should design processes and procedures that incorporate a range of threats, which is inclusive of chemical, nuclear, trauma, and highly infectious diseases. It is also recommended that PHEP and HPP awardees coordinate public messaging and information sharing with regard to case tracking by coordinating with the public information officers of multiple response partners to facilitate a consistent message.7
Existing Strategies for Facilitating Hospital Infectious Disease Preparedness
The PHEP and HPP programs assess information sharing as a capability based on the percentage of local partners that reported requested essential information to an exercise leader within a requested timeframe. This measure assesses the extent to which local response entities communicate requested information to the public health/medical lead in order to facilitate situational awareness and the effective management of resources in a timely manner.13 The measure is inclusive of a range of threats (including biological) and actors such as hospitals, public health departments (either can serve as lead), and others. Different types of information are addressed as well, including epidemiological, surveillance or lab data (e.g., test results, case counts, deaths); and points of dispensing (POD)/mass vaccination sites data (e.g., throughput, open/set-up status, etc.). Consideration is also given to differing communications systems and communication barriers, such as funding, staffing, participation, and time.13
Accreditation
Hospital accreditation agencies have established standards for compliance. CMS and the Joint Commission have recommended an all-hazards methodology for emergency management. The CMS emergency preparedness rule requires hospitals to engage in annual risk assessments and training processes, but ultimately their facilities determine what their hazards and vulnerabilities are. The ASPR Technical Resources, Assistant Center, and Information Exchange (TRACIE) website, administered by the Department of Health and Human Services, recommends in their database on Emergency Operations Plans (EOPs)/Emergency Management Programs that emergency operations plans “should be developed as an all-hazards plan and must integrate with local EOPs and coalition plans for information sharing and resource requests.” The site further recommends that specialized annexes should be included for particular types of incidents, including infectious diseases.14 The Joint Commission surveys utilize CMS standards and evaluate hospitals upon their adherence. Hospitals are required to have Emergency Operations Plans, which include listed staff roles and responsibilities and communication strategies, as well as training for roles personnel will play during emergencies. Lastly, hospitals are expected to participate in their health care system’s integrated emergency preparedness program through community-based risk assessments.Reference Bergero15
Networks and Coalitions
Well-managed health care coalitions can be an effective resource during an infectious disease emergency for coordinating health care facility activity as well as the work of other community responders. The Northwest Healthcare Response Network (NWHRN),16 established a regional response plan for infectious diseases, employing conference calls to engage in collaborative decision making on patient transport, information dissemination, and contact monitoring. A webinar-based functional exercise was also used to test the coalition’s capabilities in the areas of communication and decision-making protocols, partner coordination, and public information. The exercise involved a scenario with adult, pediatric, and pregnant patients (four in total) with an acute infectious disease. Participants were required to make decisions regarding treatment and transport of the patients, among other issues. Lessons learned included the need for a state’s department of health to be present on triage calls. Triage calls are conference calls between EMS and health care facilities that involve considering the risk stratification of a patient, taking into account their symptoms, acuity of illness, and exposure history. Consideration is also given to other patients currently under investigation. This call precedes a decision of whether to, and in what order, to transport patients to another facility. The need to make follow up calls to make sure a patient arrives at a facility and the need to discuss public information requirements and strategies were also among the lessons learned.Reference Lis and Resnick17 It should be noted that the website for the NWHRN includes valuable health care system emergency response planning materials on topics including acute infectious disease, situational awareness, and patient tracking.18
Resources provided by, the Southeast Texas Regional Advisory Council (SETRAC) highlighted the importance of early notification and communication in regard to EMS responding to an infectious disease case.19 Early notification and communication will be especially important for frontline hospitals, as their role will be to sound the alarm in the event of an outbreak such as pandemic influenza or a localized norovirus outbreak, contain the spread to the degree possible, and work with public health and community partners like school systems to try to help manage infection in the community. In addition to exercises, there are numerous other strategies health care organizations could use to better share information, including the employment of electronic health records and travel notifications (e.g., alerts to health care providers when patients indicate they have recently traveled to an area with an active outbreak), as well as adopting more streamlined information management systems, such as WebEOC, Live Process, and EMSResource.Reference Carrier, Yee, Cross and Divya20
Facility and System-Level
Toner discussed situational awareness as a critical need in public health emergency preparedness and response and recommended using health care coalitions to collect information from their members and report it to state and federal authorities.Reference Toner21 If facilities in a coalition had a technological mechanism by which information (such as data collected using syndromic surveillance), indicating a developing emergency, could be directed into a shared system it could help with early notification. Syndromic surveillance systems are designed to use data generated by emergency department records or pharmacy prescriptions to detect the emergence of an event like a biological attack, by employing statistical methods to detect aberrant patterns in behavior.Reference Thomas, Yoon, Collins, Davidson and MacKenzie22 Toner notes electronic health records (EHRs) as a potential tracking tool within offices and also recommends giving public health offices access to clinical hospital data (while making sure to comply with the Health Information Privacy and Accountability Act (HIPAA).Reference Toner21
Communication has shown itself to be inseparable from effective response. Barnum, Dietz, and Black,Reference Branum, Dietz, Black, Dietz and Black23 discuss a tabletop exercise wherein communications was not included as one of the key objectives but then emerged as an issue in a variety of ways throughout the exercise. Who in hospitals would communicate changes to the public and the staff? How would hospitals communicate their need for additional resources? This goes to show how dependent effective response is on good communications. Key aspects of an infectious disease exercise, particularly for a frontline hospital, would be communicating the presence of a threat, communicating with local, state, and federal stakeholders on a coordinated response, communicating updated data as it is collected, and communicating the need for additional resources.
Weaknesses in Existing Strategies
An overall weakness of the current system is that, while the federal government and the Joint Commission can assess whether health care facilities have taken certain steps such as reviewing plans and holding meetings with partners, the degree to which those plans will hold up under the strain of a major event cannot be truly assessed ahead of time. Furthermore, the CMS preparedness rule requirements involving the documenting of efforts by health care facilities to work with government officials and other community partners has already been weakened through revision.24 While the CMS rule was modified in February 2019 to include emerging infectious disease as part of the all-hazards definition,25 the COVID-19 pandemic is just the most recent and dramatic example of why infectious diseases need to be given special attention due to such emergencies’ complexity and tendency to erode health system capacity.
The Hospital Preparedness Program does provide funding for the Regional Treatment Network for Ebola and Special Pathogens and the National Ebola Training and Education Center.26 However, the guidance on Ebola treatment hospitals is only a set of recommendations and has multiple gaps in regard to the role of frontline hospitals. The HPP funding is helpful, but too non-specific to ensure hospitals are investing in infectious disease preparedness. Additionally, the level of funding for federal preparedness programs has been in steady decline and must be stretched even further as more facilities join coalitions as a result of the CMS rule.Reference Watson, Watson and Gastfriend27
The discussion above has identified three key challenges standing in the way of hospitals investing in and substantially improving preparedness for infectious diseases. Many after-action reports from real incidents and exercises at the federal, state, and local levels have cited communication and information sharing as a key challenge among partners.28-31 These challenges are exacerbated by other issues, including personnel, funding, and equipment needs. Addressing the issues above will require making changes to the existing structure in which facilities are expected to operate to produce improved levels of preparedness.
The Bipartisan Commission on Biodefense report put forward a recommendation to create a national, stratified system of hospitals to facilitate cooperation between federal, state, and local providers in the midst of a public health emergency where medical surge is necessary.32 Such an approach should be supported as long as it serves to create stronger networks between facilities, and that facilities were given clear guidance and expectations as to what their role in the system is. The outcome should be to bolster overall preparedness within the system. Stronger networks, in preparation for an infectious disease incident, will also be shaped through regular exercises.
CONCLUSIONS AND RECOMMENDATIONS
The mission of the Hospital Preparedness Program is to better enable facilities to prevent and respond to threats. The program needs to be more strategic in the manner in which it attempts to create national capacity for dealing with high risk pathogens. The HPP has required the development of health care coalitions around the country, many of which are models for effective coordination. These coalitions have already been called upon to help facilitate the implementation of the CMS rule, which requires regular training and maintenance of effective communication. The unique coordination and communication challenges surrounding infectious disease response should be given specific and unique consideration during the training and communication improvement process. As we have seen with the COVID-19 response, infectious diseases have a particular ability to degrade the medical and public health systems as facilities become overburdened, providers become ill, and critical equipment runs out.
A PHEP case study provides a good example of the problems in the system with respect to information sharing between health care and public health. A state PHEP awardee found that their communications and information sharing during the H1N1 response was disjointed, with some health care providers acting on information from public health and others acting on information from elsewhere. As a result, they incorporated information sharing into the work plan related to their award, including “identifying points of contact, optimal data sharing mechanisms, and the types of pertinent information that HCOs will need to receive in order to make informed decisions.”33 The awardee allocated about 10% of its award to information sharing and planned to provide funding to district health offices to build information sharing capabilities. A collaborative planning meeting was held between the state and the district offices and a decision was made to incorporate pandemic influenza planning into the building of information sharing capability. While it is not clear, based on the information provided, if the awardee met its goal of having all eight district offices meet required criteria by the end of the budget period, the process that was used is in keeping with a vision of making information sharing more vital to the HPP process and illustrates the importance of information sharing to infectious disease control.Reference Koenig, Schultz, Runnerstrom and Ogunseitan34
Regulatory requirements and funding opportunities include an emphasis on the importance of communication and training amongst hospitals in the event of an emergency involving a high-consequence pathogen. Effective information sharing, as we have seen during the COVID-19 and other infectious disease responses, is vital to all other elements of the response, including tracking infections, distributing resources, and maintaining staffing. Additional funding should be made available for facilities that are currently Ebola treatment hospitals (i.e., biocontainment units) for providing training and education for frontline hospitals. Utilizing these hospitals for train-the-trainer efforts would strengthen frontline hospital readiness without burdening federal agencies. Communicating best practices and personal experiences would serve to promote better surveillance and situational awareness as well as overall preparedness by giving frontline hospitals a stronger sense of what to be on alert for. At the same time, ‘lessons learned’ through responses and exercises should be studied systematically to evaluate generalizability.Reference Koenig, Schultz, Runnerstrom and Ogunseitan34 Training would also facilitate the building of relationships between personnel in frontline and treatment hospitals that can facilitate more effective communication and information sharing in the event of a real response.
America’s imperative must be to make the federal system work in as effective and coordinated a manner as possible in the event of an epidemic or pandemic emergency. Our policies need to provide frontline providers with the funding, technology, and policy infrastructure to mount such a response, cognizant of the fact that they will be dependent upon information coming from a variety of sources. More attention must be paid to how to create a flexible framework for health care institutions that makes their responsibilities clear and provides the necessary support system, including effective communication mechanisms.
