Jonathan L. Burstein

Health care facility and community strategies for patient care surge capacity

Abstract Recent terrorist and epidemic events have underscored the potential for disasters to generate large numbers of casualties. Few surplus resources to accommodate these casualties exist in our current health care system. Plans for “surge capacity” must thus be made to accommodate a large number of patients. Surge planning should allow activation of multiple levels of capacity from the health care facility level to the federal level. Plans should be scalable and flexible to cope with the many types and varied timelines of disasters. Incident management systems and cooperative planning processes will facilitate maximal use of available resources. However, resource limitations may require implementation of triage strategies. Facility-based or “surge in place” solutions maximize health care facility capacity for patients during a disaster. When these resources are exceeded, community-based solutions, including the establishment of off-site hospital facilities, may be implemented. Selection criteria, logistics, and staffing of off-site care facilities is complex, and sample solutions from the United States, including use of local convention centers, prepackaged trailers, and state mental health and detention facilities, are reviewed. Proper pre-event planning and mechanisms for resource coordination are critical to the success of a response.

Clinical Safety of Lidocaine in Patients With Cocaine-Associated Myocardial Infarction☆☆☆★

STUDY OBJECTIVE To evaluate the safety of lidocaine in the setting of cocaine-induced myocardial infarction (MI). DESIGN A retrospective, multicenter study. SETTING Twenty-nine university, university-affiliated, or community hospitals during a 6-year period (total of 117 cumulative hospital-years). PARTICIPANTS Patients with cocaine-associated MI who received lidocaine in the emergency department. RESULTS Of 29 patients who received lidocaine in the setting of cocaine-associated MI, no patient died; exhibited bradydysrhythmias, ventricular tachycardia, or ventricular fibrillation; or experienced seizures after administration of lidocaine (95% confidence interval, 0% to 11%). CONCLUSION Despite theoretical concerns that lidocaine may enhance cocaine toxicity, the use of lidocaine in patients with cocaine-associated MI was not associated with significant cardiovascular or central nervous system toxicity.

Outcome of patients who refused out-of-hospital medical assistance

Activation of the emergency medical services (EMS) system does not always result in transport of a patient to the hospital. This study assessed the outcomes of patients who refused medical assistance in the field, to determine if refusal of medical assistance (RMA) is associated with poor outcomes. Four high-volume suburban volunteer ambulance corps participated in the study. Consecutive patients who refused medical assistance were prospectively enrolled. Medical and identifying data were collected for each patient. Telephone follow-up was conducted to determine the patients condition and if the patient sought further care after RMA. Primary endpoints were whether the patient sought further care, was admitted to a hospital, or died subsequent to RMA. Follow-up was successfully obtained for 199 of 321 patients enrolled (62%). Of these 199 patients, 95 (48%) sought further medical care within 1 week for the same complaint, with 13 being admitted to the hospital. Six of the 13 admitted patients had chief complaints of a cardiac or respiratory nature. One patient died during hospital admission. Even if none of the patients lost to follow-up had sought further care, a substantial number of patients who refuse out-of-hospital medical assistance seek further care. Some of these patients require hospital admission, especially those with cardiac or respiratory complaints. Efforts to minimize RMA should be especially focused on patients with such complaints.

Protective equipment for health care facility decontamination personnel: regulations, risks, and recommendations.

After recent terrorist attacks, new attention has been focused on health care facility decontamination practices. This article reviews core issues related to the selection of appropriate personal protective equipment for health care facility decontamination personnel, with an emphasis on respiratory protection. Existing federal regulations focus primarily on scene response and not on issues specific to health care facility decontamination practices. Review of existing databases, relevant published literature, and individual case reports reveal some provider health risks, especially when the exposure involves organophosphate agents. However, reported risks from secondary exposure to contaminated patients at health care facilities are low. These risks should be adequately addressed with Level C personal protective equipment, including air-purifying respirator technologies, unless the facility determines that specific local threats require increased levels of protection.

The National Report Card on the State of Emergency Medicine: Evaluating the Emergency Care Environment State by State 2009 Edition

Becher • Editorial E this year, the American College of Emergency Physicians (ACEP) released its first-ever National Report Card on the State of Emergency Medicine with the intention of bringing the critical issues confronting emergency care in the United States before the public eye. The ACEP Report Card is an assessment of the support that each state provides for its emergency medicine system. The January 2006 report card is the first in a proposed series that the ACEP plans to issue, and it will serve as a baseline measure for comparison with future changes as data become available from state government offices. It is hoped that the results of the ACEP Report Card will serve as a much-needed wake-up call to state legislators and the public that the system they depend on for lifesaving emergency care is itself in critical condition. For the first time, the public saw the support—or lack of support—provided by the states to their local emergency care systems. The ACEP Report Card analyzed 2500 data points, all directly related to the financial support provided by the individual states. This was the first definitive look at the entire range of issues confronting the provision of emergency care. Fifty objective and quantifiable criteria were used to measure the performance of each state and the District of Columbia. These measurements were weighted and aggregated, and grades were assigned based on comparison to the best state’s performance (ie, a “sliding scale”). Each state received an overall grade as well as individual grades in each of four specific categories. Recognizing that not all categories or criteria were of equal importance, the task force assigned weighted scores to reflect “real world” priorities: ▫ access to emergency care, 40%; ▫ quality and patient safety, 25%; ▫ public health and injury/crisis prevention, 10%; and ▫ medical liability environment, 25%. It is important to note that these grades are not evaluations of the quality of care provided by emergency physicians, residency programs, or hospital emergency departments. Rather, the grades in the ACEP Report Card show the overall effort of states to support effective emergency medicine systems. Local emergency departments are at the front line of a national healthcare crisis. They are increasingly crowded— often to the point that ambulances en route must be diverted to another hospital.1,2 A key cause of emergency department crowding is the lack of staffed inpatient beds.1,2 Another cause of crowding is the high cost of medical liability insurance, which has led some specialty physicians to leave the practice of medicine or to be less willing to be “on-call” for emergency situations, aggravating hospitals’ difficulties in providing emergency care.3 The ACEP Report Card indicates that the national emergency healthcare system is in serious condition, with many states in critical condition. While no state received an overall failing grade, many have serious deficiencies, and almost all states have areas in which there is substantial room for improvement. Currently, emergency care is this country’s safety net for the entire healthcare system.2 The growing number of uninsured citizens, the lack of participation in preventive health programs, and the relentless demographic shift that accompanies the baby-boom generation all contribute to the increasing burden on the emergency medicine system.2,4,5 No state received an overall grade of A, and only California, Connecticut, Massachusetts, and Washington, DC, earned a solid B. A summary of the grades for the states with the highest number of hospitals accredited by the American Osteopathic Association (AOA) is provided in Table. Clearly, in those states with the worst environment for medical liability reform, the effects of a low score for that portion of the formula (25%) would have a negative impact on the overall grade. Therefore, those states in which emergency departments have closed because medical specialists such as neurosurgeons, obstetricians, and orthopedists could not obtain medical liability insurance would be inclined toward lower overall scores than states with more reformfriendly environments. States with hospitals that do not have critical on-call specialists available because of a fear of lawsuits would be similarly affected. The AOA, American Medical Association, and ACEP advocate several possible solutions to the crisis in emergency medicine, including: The National Report Card on the State of Emergency Medicine

Establishing and training health care facility decontamination teams

Recent terrorist events, changes in Joint Commission on Accreditation of Healthcare Organizations requirements, and availability of grant funding have focused health care facility attention on emergency preparedness. Health care facilities have historically been underprepared for contaminated patients presenting to their facilities. These incidents must be properly managed to reduce the health risks to the victims, providers, and facility. A properly equipped and well-trained health care facility team is a prerequisite for rapid and effective decontamination response. This article reviews Occupational Safety and Health Administration (OSHA) training requirements for personnel involved with decontamination responses, as well as issues of team selection and training. Sample OSHA operations-level training curricula tailored to the health care environment are outlined. Initial and ongoing didactic and practical training can be implemented by the health care facility to ensure effective response when contaminated patients arrive seeking emergency medical care.

Complaints and compliments in the pediatric emergency department

We conducted an analysis of all communications received from patients or their families by the director of a pediatric emergency department over a three-year period, during which approximately 150,000 visits occurred. Communications were characterized as complaint or compliment and subclassified by type: waiting time, staff attitude, quality of medical care, and billing, x2 analysis was used to identify factors that predisposed to complaint or compliment and to identify the subtype. After quality-of-care issues, complaints stemmed most often from billing issues or waiting time for care for nonurgent disorders (especially medical problems), while complimentary letters most frequently addressed staff attitude and quality of care. The problems that we identified might be addressed by providing families improved access to non-emergency department care sources, education regarding the role of an emergency department, and better explanation of billing procedures during the registration process. Additionally, our findings serve as a reminder that many parents appreciate the care given to their children, particularly for life-threatening emergencies.

Building community-based surge capacity through a public health and academic collaboration: the role of community health centers.

To improve national emergency preparedness, multiple levels of the public health system require strengthening. One major area is surge capacity,1 defined by the Agency for Healthcare Research and Quality (AHRQ) as “a health care system’s ability to rapidly expand beyond normal services to meet the increased demand for qualified personnel, medical care, and public health in the event of bioterrorism or other large-scale public health emergencies or disasters.”2 The aftermath of Hurricane Katrina and increasing concerns about a possible avian flu pandemic have focused more attention on this issue, especially regarding disadvantaged and special needs populations.3 While national agencies such as AHRQ, the Centers for Disease Control and Prevention (CDC), and Health Resources Services Administration (HRSA) have cited surge capacity as a priority “focus area,” current published literature is sparse. A MEDLINE search yielded few relevant resources, and those focus primarily on hospital settings.4,5 Non-hospital settings, such as community health centers (CHCs), also offer potential. In this article, we describe a collaboration among CHCs, government agencies, and academia that initiated the growth of community-based surge capacity in the Boston area. DEFINING THE DIMENSIONS OF SURGE CAPACITY

Integration of Academia and Practice in Preparedness Training: The Harvard School of Public Health Experience

Given the need for public health professionals well trained in emergency preparedness and response, students in public health programs require ample practical training to prepare them for careers in public health practice. The Harvard School of Public Health Center for Public Health Preparedness has been instrumental in the creation and implementation of a course entitled, “Bioterrorism: Public Health Preparedness and Response.” This course features lectures on specific applications of public health practice in emergency preparedness and response. In addition, it provides students the opportunity to operationalize and apply their knowledge during an interactive tabletop exercise. In light of their university affiliations and expertise in providing preparedness training, other Academic Centers for Public Health Preparedness have the opportunity to be instrumental in providing similar training to graduate students of public health.

Smoke and Shadows: Measuring Hospital Disaster Preparedness

At 0247 in the midwatch, as the USS Patrol is cruising in the Strait of Malacca, a radar technician sees an unusual tracing on her screen. In less than a minute, she and the ESM tech next to her have identified it as an inbound sea-skimming missile and called it out to the Combat Information Center team. Within seconds after that, the Officer of the Deck has roused the ship to general quarters, and scant minutes thereafter the well-trained sailors just out of bed have shot down the threat before it came close to them. Some of them may not have even realized they were targeting a real missile, but they carried out their jobs flawlessly. Military action provides perhaps the ultimate metric for “disaster” readiness. From a standing start, a team needs to be prepared to respond to a sudden threat, with failure resulting in injury or death. As a result, military training and operations requires constant and realistic practice, and it is fair to say that a well-trained military unit will be “ready” to conduct its standard warfighting missions simply because it performs close facsimiles of those actions regularly. Except perhaps in the narrow spheres of trauma care or management of cardiac arrest, civilian hospital readiness for disasters has traditionally been much less tightly programmed and practiced. As a result, it remains to this day hard to say what it means to declare that a hospital is “ready” for a disaster. In this issue of Annals, 2 teams of researchers have tried to actually measure how ready their hospitals were for major disasters, using in one case a complex rating tool for actual drill response behavior and in the other a comparison of actual response versus the “quality” of prewritten plans. Kaji et al tested a drill evaluation checklist (developed through the Agency for Healthcare Research and Quality) at drills involving 6 hospitals. They used teams of trained observers to score the instrument and found overall that although the “tool” itself had high internal reliability, the interrater reliability was much lower. In short, 2 observers looking at the same response (such as actions taken in a hospital emergency department) could have differentially graded it as “excellent,” with most items in that rater’s questionnaire consistently reflecting top performances, and “poor,” with most items in that rater’s questionnaire consistently reflecting inept performances. The research team points out that this variability may be due to problems with the observers (insufficient training or inability to understand what they were supposed to be