Advancing Medical Countermeasures Dispensing

The delivery of medical countermeasures such as antibiotics and vaccines during a public health emergency has been identified as one of the major challenges facing the medical and public health communities. In March 2008, the Forum hosted a workshop on medical countermeasures dispensing that engaged a broad community from the public and private sectors to discuss innovative strategies.1 Two specific highlights of the discussion—the liability concerns of the business sector and the value of using the US Postal Service for countermeasures dispensing—have since been addressed in new federal policies. A second workshop on November 18, 2009 will enhance progress and address current vulnerabilities by discussing the policy implications of emergency use authorization and strategies to limit potential logistical challenges that could delay the expeditious dispensing of medical countermeasures to populations at risk.

Identifying Opportunities to Enhance Medical Surge Capacity

In response to a request from the US Department of Health and Human Services' Assistant Secretary for Preparedness and Response, the Forum convened a 2-day workshop in June 2009 to explore strategies to improve medical surge capacity in the United States. The workshop discussions were designed to help inform the efforts of the Hospital Preparedness Program of the Department of Health and Human Services. Forum members and workshop participants discussed the need to adopt a systems approach at the regional level with coordination among hospitals, alternative care systems, and emergency medical services, so that demand could be managed and surge allocated appropriately to ensure the best care possible in the best place under the circumstances. The participants suggested “thinking outside the box” about providing care during a response with regard to who, where, and with what tools.

Several participants pointed out that developing and using detailed definitions, such as Hick, Barbera, and Kelen's conventional, contingency, and crisis surge capacity continuum,Reference Hick, Barbera and Kelen2 may enable health systems to develop a structured, measured response that would have the least possible impact on standards of care, and would facilitate meaningful communication about surge capacity throughout the preparedness community. Many participants also stressed the importance of developing performance expectations and metrics to evaluate progress. A number of speakers presented new technologies and strategies to enhance systemic situational awareness, but indicated that efforts to scale up and achieve interoperability, develop indicators of distress and triggers for action, aggregate and integrate supply-side information, and encourage use by a wide range of stakeholders were in early developmental stages.

The need for a more comprehensive approach to ensuring appropriate care for vulnerable populations was emphasized. Other important but often overlooked topics addressed during the workshop include developing a national mass fatality management strategy, ramping down after a response to a mass casualty incident, and financing surge capacity and preparedness.

Developing Policies for Standards of Care During Mass Casualty Events

A catastrophic public health event that involves thousands or tens of thousands of victims will overwhelm the ability to deliver care according to the established standards of care in our health care system. Although many local, state, and federal preparedness efforts have been initiated, a recent report on state preparedness by the US Government Accountability Office concluded that among the key components of medical surge planning, “standards of care during a mass casualty event” remained in the greatest need of significant additional attention and planning.3 In spring 2009, the Forum hosted a series of regional meetings on standards of care in Irvine, CA, Orlando, FL, New York City, and Chicago. The meetings were designed to describe and demonstrate the current local, state, and regional efforts under way to establish alternative standards of care policies, and to improve regional efforts by facilitating dialogue and coordination among neighboring jurisdictions. Federal, state, and local officials, representatives from a wide range of provider communities, and hospital and health care administrators presented their efforts and participated in extensive discussions about current progress, barriers, and challenges.

The regional meetings highlighted many innovative local and regional models and addressed the logistical, legal, and ethical challenges associated with policies for standards of care. Participants also identified important areas for future work on standards of care, including the development of consistency both within a region and across regions, more evidence-based research on what may and may not work, increased attention to palliative care, and engagement with providers and the community. Many of these important issues were addressed in a subsequent Institute of Medicine committee report on guidance for establishing crisis standards of care for use in disaster situations.4

Integrating Preparedness Into the Health System

The essential vision for health care reform should include the concept of a resilient and prepared health system that preserves and protects life by ensuring routine and emergency access to safe, high-quality, efficient, effective, and patient-centered care. With this in mind, the Forum organized a discussion on health care reform and preparedness in June 2009. Meeting participants articulated the need to establish a health system that is resilient, that can meet the demands faced in the day-to-day delivery of care, withstand economic adversity, and respond to and overcome the challenges that arise during public health emergencies and disaster medical responses.

Meeting participants identified 5 near-term opportunities that, if addressed, could improve the quality and resiliency of the health care system. The first opportunity is the development of health information technology that includes interoperable, secure, scalable, and reusable standards and protocols that facilitate transitions of care and build a resilient health care infrastructure for daily activity as well as for public health emergency and disaster medical responses. The second opportunity is that primary care providers and community health centers could play an important role in developing community resilience and mitigating the surge burden on hospitals through integration of these functions in the development of a medical home model. The other opportunities emphasize the importance of encouraging workforce development and training for service during emergencies, support for regional approaches that improve the day-to-day and during-disaster quality and efficiency of health care, and the need for increased attention to the behavioral and mental health of victims of public health emergencies and disasters.

As part of its efforts to further integrate and enhance preparedness, the Forum will host a workshop October 29–30, 2009 to provide stakeholder input and review of the National Health Security Strategy (NHSS), a congressionally mandated quadrennial strategy for public health emergency preparedness and response. In addition to outlining strategic goals, the NHSS will also include an assessment of the preparedness of federal, state, and local public health and medical capabilities. The workshop will provide participants an opportunity to propose and discuss innovative ideas and strategies for implementing the priorities identified by the NHSS, and will feature invited presentations and discussions focused on ensuring resilience by creating a culture change, strengthening the medical and public health preparedness system, and sustaining national preparedness.