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PUBLIC HEALTH: Are Hospital ERs Prepared To Handle Disaster?



June 27th, 2007

How prepared are U.S. hospital emergency rooms to handle a public health emergency stemming from natural disaster or pandemic? According to witnesses and Members of Congress at a hearing of the House Oversight and Government Reform Committee last Friday—not very. Rep. Elijah Cummings (D-MD), who chaired the hearing, said in his opening statement:

“Last summer, Congress enacted the Pandemic and All Hazards Preparedness Act. This Act assigned responsibility for leading all federal public health and medical responses to public health emergencies to the Department of Health and Human Services [HHS]. But despite this clear responsibility, and despite the billions of taxpayer dollars that the Congress has appropriated for biodefense and pandemic preparedness, HHS appears to be ignoring the mounting emergency care crisis.”

“The Department has not made a serious effort to identify the scope of the problem and which communities are most affected. It has failed to require hospitals that participate in Medicare to report data on the extent of ER boarding and ambulance diversion. It has failed to use its purchasing power through the Medicare program to encourage hospitals to promptly admit ill and injured patients to inpatient units, rather than “boarding” them in ER hallways and forcing staff to divert inbound ambulances. It has done nothing to promote regionalization of highly specialized trauma and emergency care services — a key recommendation of the [June 2006 Institute of Medicine] IOM report.”

Kaiser Daily Health Report elaborated on the back and forth between the House committee and the HHS Centers for Medicare and Medicaid Services (CMS):

“Cummings was “clearly irritated” that CMS administrator Leslie Norwalk failed to attend the hearing, CQ HealthBeat [subscription required] reports. CMS spokesperson Jeff Nelligan said that the agency asked the committee to reschedule the hearing, adding that the committee refused the request. He said, “However, we have provided written answers to several questions for which CMS input was sought.”

Committee Chair Henry Waxman (D-CA) on Friday sent additional questions to Norwalk about the actions that CMS has taken to address the practice of boarding, in which hospitals admit ED patients when no rooms are available and leave them in hallways for extended periods of time, and diversion, in which hospitals reroute ambulances because their EDs have reached capacity. Waxman asked Norwalk to respond by June 29 (Carey, CQ HealthBeat, 6/22).”

Lead witness William Schwab, a physician who served on the IOM commission that generated the report on the crisis in emergency room care, testified:

“It is a hidden problem. It has been swept underneath the rug continuously. And it may be being swept under the rug because people believe that there is no good way to solve it and the only way to solve it is throw money at it…. I am absolutely shocked that there hasn’t been more done in the last year, even just simple communication about how we could help our government agencies and we could partner as health care, medicine, and nursing to help fix this. We do need to look at better coordination from the government.”

“We truly believed in the Institute of Medicine and in our committee that it was spread out to too many agencies. There’s no one agency that’s responsible. There’s no champion for emergency care.”

Concerns about ER care are not new. But now that Democrats are in control of Congress, with Reps. Cummings and Henry Waxman (D-CA) in possession of congressional gavels, there is new pressure from the Hill for government to take a more activist role in addressing ER boarding and ER surge capacity in anticipation of epidemics and bioterrorism.

A year ago, Health Affairs devoted an issue of the journal to “The State of Public Health” and featured papers on the evolution of preparedeness by Nicole Lurie and colleagues and preparing for bioterrorism in the wake of 9/11 by Aaron Katz and coauthors [both papers 2-week free access]. And tales of emergency room crises abound. [See, for example, the free access Narrative Matters essays by Jay Himmelstein and Philip Musgrove].

In the meantime, the American Medical Association has just launched a new journal devoted to the topic of public health preparedness. The first issue of the journal Disaster Medicine and Public Health Preparedness looks at Hurricane Katrina, the 1995 Oklahoma City bombing, and the 2004 Indonesian tsunami. The journal has a free online trial running until July 22, 2007.

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