Northern Virginia

The Northern Virginia Hospital Alliance (NVHA) was formed in October 2002, an effort initiated by two of the three recognized leaders of the NVERC. Although the NVERC “coalition” focus was deemed vitally important and was very successful during its relatively brief duration, it became clear that specific needs of the northern Virginia hospitals regarding planning and response required a different approach than that required by their municipal public health, law enforcement, fire, and EMS partners. NVHA is comprised of 14 member hospitals and 6 freestanding fully functional emergency departments in the northern Virginia suburbs of Washington, DC. It includes facilities that serve a population of more than 2.5 million residents over 3,000 square miles—ranging from suburban to exurban to rural communities. The hospitals have more than 3,500 acute care beds, and provide more than 700,000 ED visits and more than 170,000 hospital admissions (2009 data). As a conglomerate, the NVHA member hospitals have over 40,000 employees, making them the largest private-sector employer in northern Virginia.¹¹

The organization was conceived as both a planning and response entity, with an initial focus placed on creating the sort of real-time information sharing and management system that was noted to be sorely lacking during the 2001 attacks. A regional hospital coordinating center (RHCC) was developed, and an 800 MHz radio system was put in place as the result of a public/private partnership entered into with northern Virginia’s largest municipality, Fairfax County. Other key efforts included development of a regional focus on chemical event preparedness, with coordinated purchasing of a regional cache of personal protective equipment (PPE), development of an integrated approach to surge capacity and capability that has included an element of telemedicine to assure immediate availability of medical expertise and oversight, and a robust pharmaceutical and materials acquisition, storage, and logistics plan, including the development of a warehouse capacity, to ensure availability of key resources separate from state or federal stockpiles. The NVHA remains a robust and vital planning and response organization to the present time, led by an Executive Director and governed by an active Board of Directors comprised of the CEOs or senior most administrators of each of the region’s 14 hospitals.

In the aftermath of the 9/11 and anthrax attacks, Arlington County, Virginia, which was one of the last of the original 120 MMRS-funded “cities,” brought forward the recommendation to expand its MMRS program to include some of its northern Virginia neighboring jurisdictions. In 2005, the Northern Virginia Emergency Response System (NVERS) was created, representing 25 towns, cities, and counties with approximately 2 million residents. NVERS supports “a regional approach to coordinated preparedness, response, mitigation and recovery across jurisdiction and discipline boundaries during day-to-day emergencies and multi-jurisdictional and/or multi-disciplinary incidents through strategic planning, priority-setting, information sharing, training, exercises, equipment acquisition and policy-making.”¹² It provides for coordination on planning and integration of response capabilities across law enforcement, fire and rescue, emergency medical services, hazardous materials, emergency management, hospitals, public health, public information and information technology. It coordinates closely with its state partners in the Commonwealth of Virginia, as well as with its regional partners in the State of Maryland and the District of Columbia, and partners closely with many of those same entities who help to comprise the Metropolitan Washington Council of Governments.

Suburban Maryland

The focus on planning and response to disaster events in the State of Maryland preceded those outlined for the District of Columbia and the Commonwealth of Virginia. The Maryland Institute for Emergency Medical Services System (MIEMSS), founded by the Governor of Maryland in 1973, placed emphasis on the development of a “system” that coordinates the delivery of emergency pre-hospital and hospital-based care. The central role played by MIEMSS in organizing out-of-hospital and hospital emergency capabilities has led to a different approach to the development of regional hospital coalitions. In the years prior to the 9/11 attacks, these efforts developed in parallel with the hospital-specific planning efforts of the DCHA and EMS focused disaster planning occurring in northern VA. MIEMSS created a seamless statewide radio network linking the state’s hospitals that has been in operation for nearly three decades. The state Emergency Medical Resource Center (EMRC) was founded in 1974, representing one of the first systems in the nation to emphasize and develop coordination of EMS and hospital communications, for use both day-to-day and during disaster events. In the aftermath of the region’s experience with the 9/11 attacks, an information management platform focused on facility resources data collection an information sharing system was put into place.

Given the strong state influence on planning, efforts at coalition building have been somewhat limited compared with the DC and VA efforts. In 2004, the Bethesda Hospitals’ Emergency Preparedness Partnership (BHEPP) was established, creating a planning and response link among the local community hospital, which is an accredited Level 2 trauma center, and the federal medical facilities at the National Institutes of Health (NIH) and the National Naval Medical Center (formerly Bethesda Naval Medical Center, now renamed the Walter Reed National Military Medical Center).¹³ In addition, the National Library of Medicine, co-located on the NIH campus, is an active member of the partnership. This geographically concentrated effort has conducted and participated in numerous exercise events focused on coordinating municipal, regional, and federal emergency response agencies. By coordinating their response capabilities, they have effectively developed a significant capacity to manage a sudden influx in patient care needs. They have been an active and engaged partner in planning efforts occurring across the National Capital Region.

More recently, the Suburban Maryland Hospital Coalition has been established, comprised of the 10 hospitals located in the close in Maryland suburbs of Washington, DC, located in Montgomery and Prince George’s Counties (and incorporating the three aforementioned hospitals comprising the BHEPP). This entity is a planning group only, focused on the coordination of ASPR/HPP-related funding opportunities. However, the central Maryland area hospitals signed a regional sharing agreement for the first time in 2012, including four hospital signatories from the suburban Maryland region, in order to support a disaster event affecting Baltimore hospitals. The voluntary Baltimore Health Care Facilities Regional Mutual Aid System’s MOU has formalized the process of collaborating in the event that one hospital becomes overwhelmed during a disaster. This agreement allows all participating hospitals to work together during an emergency to share staff, beds, equipment, and supplies.¹⁴

District of Columbia

As previously described, the DCHA played a crucial role with regard to coordinating the DC hospitals for disaster planning and response. However, 5 years after the 2001 attacks, the leadership provided by DCHA in the emergency preparedness efforts of the DC hospitals transitioned to the DC Emergency Health Care Coalition (DCEHC), which was funded by an ASPR grant in 2007. Membership includes seven acute care hospitals and a combination of 40 skilled nursing facilities and community health centers. DCEHC was developed along the parameters established in the Medical Surge Capacity and Capability Health Care Coalition in Emergency Response and Recovery handbook.¹⁵ It is staffed by a Health Care Coalition Response Team (HCRT), Senior Policy Group, and has created a Coalition Notification Center (CNC) which utilizes an on-call Duty Officer. The CNC rotation among three DC hospitals facilitates information exchange to Coalition members and external partners by use of the HMARS radio system and a health information management platform. By doing so, the DCEHC has come into sync with the NVHA and its Regional Hospital Coordination Center (RHCC) and the State of Maryland’s EMRC, in being able to communicate in real time among and between the three regional health care partners of the NCR during day-to-day alerts, and in support of response to disaster events (see Table I-1).

TABLE I-1

NCR Health Care Coalition Communications Network.

Coordinating Across the NCR

Because so many planned events occur in the Nation’s Capital—the presidential inauguration every 4 years, the yearly State of the Union presidential address, and July 4 celebration—and because Washington’s buildings and their occupants remain high threat targets for terrorists seeking to inflict damage, coordinating communications and response activities across the NCR is of critical importance. FEMA’s after-action report detailing the planning and response activities related to the 2009 Presidential Inauguration of Barack H. Obama highlighted, among other items, the unprecedented degree of planning coordination and cooperation that occurred in support of this historic event, particularly in the public health and medical sectors:

Hospital coalitions and individual institutions took a wide range of steps to plan and prepare for the Inauguration. The DC Emergency Health Care Coalition (DCEHC), the DC Hospital Association (DCHA), and the Northern Virginia Hospital Alliance (NVHA) developed plans and worked with their members to prepare for the Inauguration. These entities developed emergency operation plans, incident action plans and other documents to coordinate their members’ response activities. Northern Virginia hospitals integrated their planning activities to a degree that exceeded their previous efforts. Further, the DCEHC led efforts to create a NCR hospital incident information sharing procedure for the Inauguration. ¹⁶

In addition to coordinating the planning efforts, the operational elements required to ensure close synchronization of response efforts were also put into place. The DC Department of Health Health Emergency Coordination Center (HECC) was utilized during the Inauguration weekend to serve as a coordinating point for information relevant to the NCR hospitals and public health agencies, and was staffed by members comprising the DC, MD, and northern VA hospital coalitions, health departments, and EMS agencies. The recommendation from the FEMA report was that “NCR hospital and EMS partners should identify opportunities to institutionalize these processes in order to prepare the region for largescale, no-notice events.”¹⁷ Similar efforts will have been used in coordinating planning and response to this year’s 2013 Presidential Inauguration.

One area in which the FEMA report noted a need for improvement was in developing consistency among NCR hospitals with regards to sharing a common set of terms and definitions to describe their ability to accept patients. The three different jurisdictions each utilized words and phrases that were not in use by the other jurisdictions: “Open, Special Diversion, and Closed”; “Green, Yellow, and Red”; and “Baseline, Stressed, and Overwhelmed” were all used to describe hospital surge capacity status. As a result, “during the Inauguration, officials unfamiliar with the terminology disseminated an announcement predicated on an erroneous understanding of hospital status. This incident illustrates how officials unfamiliar with the differing terminology may make erroneous assumptions and conclusions about hospital status.”¹⁸

As a direct result of this experience, the NCR coalition partners have undertaken efforts to standardize hospital terminology throughout the region, and have drafted an “NCR Hospital Event Information Sharing Procedure.” It is intended to provide guidance to the hospital coordination centers located in DC, suburban Maryland, and northern Virginia in the procedures required to facilitate effective information sharing during planned events and major incidents. This draft policy establishes the notification criteria that would warrant region wide information sharing (see Box I-1).¹⁹

BOX I-1

Notification Criteria for National Capital Region Hospital Information Sharing, from “NCR Hospital Event Information Sharing Procedure,” Draft Document, June 19, 2012. Judgment by Health Care Coordinating Center leadership that notification of (more...)

Including Health as Part of the Emergency Response System

As described in the IOM report detailing the development of crisis standards of care, coordination of the entire emergency response system is required in order to best mitigate the consequences arising from a catastrophic disaster event.²⁰ This “system” includes those elements traditionally considered to be a part of emergency response—police, fire, and EMS agencies, but must also include other partners, as well. Hospitals, public health agencies, and the private practice medical community are also key components. Early planning efforts funded under the Metropolitan Medical Response System grants of the late 1990s, followed by the weaknesses exposed by the 9/11 and anthrax attacks of 2001, highlighted the importance of bringing health and medical entities to the table as full partners in planning and response. Thus, the emergency response system is now intended to be inclusive of public health agencies and strives to include those elements involved in the delivery of acute medical care—hospitals, clinics, and the private practice community. However, inclusion of the private practice health care practitioners in the emergency planning and response process remains mostly elusive.²¹,²² Nonetheless, as exemplified by the NCR coalition development experience, the transition to a comprehensive systems approach to preparedness and response is slowly occurring in communities across the nation.

Health care coalitions may be in the best position to help broker such change. The intent of federal grant funding, particularly that coming from the ASPR/Hospital Preparedness Program, is focused to ensure that such connectivity continues to be developed and planned for. The enhancement and maturation of such connections are vitally important to the success of any response to a catastrophic event. As the National Guidance for Health Care System Preparedness document highlights, “health care coalitions, in coordination with health care organizations, emergency management, ESF (emergency support function) # 8, relevant response partners and stakeholders (must) develop a plan to ensure health care organizations are represented in incident management decisions during an incident.”²³

The health care coalition may be uniquely able to plan for disaster response needs irrespective of the jurisdictional issues that can often hamper planning within many of the municipality-based emergency response agencies. Coalition membership is often comprised of health care systems that have their facilities located in more than one jurisdiction. As a result, these are often organizations that are used to routinely coordinate basic public health, EMS, and related public safety issues among multiple jurisdictional agency partners. Given that the health care coalitions also chiefly represent private sector entities, more latitude in the procurement process can often hasten acquisition of key planning resources. Many times such resources may be provided by “in-kind” contributions, of both personnel and resources, which further helps to promote the planning effort. For example, the RHCC in Northern Virginia is co-located within Inova Health System’s eICU telemedicine nerve center, providing a location for a command center that takes advantage of additional functionality provided by the broadband connectivity needed for this critical care service.

Given this potential benefit, the health care coalition can help to serve as a convener of emergency response entities, much the way the DCHA and the original NVERC, and later the NVHA, did in the National Capital Region. Planning must be based upon known or perceived hazards, and must focus on the steps needed to ensure safe, timely, and evidenced-based responses to the identified risks. Such planning must take into account the ability to surge in demand for health care services, and must include plans that recognize the potential shift in care delivery across the surge spectrum from conventional to contingency to crisis surge response.²⁴ Across the varied risks that might be planned for, the health care coalition must be prepared to help manage and promote not only communications, information sharing, and situational awareness, as previously described, but other key issues, as well. Key attributes and functions of a robust health care coalition are described in Table I-2.

TABLE I-2

Core Functions and Capabilities for Health Care Coalition Development.

Development of a regional health care operations policy, one that details the allocation and sharing of key resources, and plans for their utilization across the rainbow of potential scenarios, will be an important step taken in the direction of codifying the basic procedures that will govern a response to mass-casualty, mass-exposure, and public health emergency. The purpose of such a plan ought to be to describe the systems, tools, and organizational structure by which the health care coalition will execute its basic responsibilities. As noted previously, these include facilitating communications, information sharing, and response between coalition partners and other relevant response partners at the local, regional, and state level (i.e., law enforcement, fire/EMS, public health, emergency management, and others); coordinating the management and distribution of patients from a mass casualty incident to receiving hospitals with the public safety and EMS agencies, both municipal and private; promoting coordinated and consistent strategies and tactics across the responding coalition members; and facilitating resource support to the coalition members, to include mutual aid/cooperative assistance, deployment of regional stockpiles (see Table I-3), governmental assistance, and the management of spontaneous volunteers or donations.

TABLE I-3

Example of Health Care Coalition Resource Stockpiling (from NVHA Regional EOP).

Assisting Response and Recovery—“Network-Centric” Coalitions

The IND detonation scenario will result in infrastructure damage limited to a circumscribed geographical area and, depending on prevailing weather conditions, creation of a dangerous fallout zone that will extend for a much larger distance, posing danger to many more citizens who will quickly be at risk for radiation exposure. Given that the characteristics of such an event will change rapidly over time, and in light of the importance of public messaging described earlier, a very important aspect of the response, and recovery, will be how effectively critical information will be authenticated, broadcast, and updated. The progression of health care coalition development and cross-jurisdictional coordination, as exemplified in the progress being made by the DC, suburban Maryland, and northern Virginia health care coalitions, demonstrates the importance of pursuing the concept of “networks of networks” in achieving the capabilities required for robust and resilient community response to catastrophic disaster.

Network centric, or “netcentric,” refers to the development of a “continuously-evolving, complex community of people, devices, information and services interconnected by a communications network to optimize resource management and provide superior information on events and conditions needed to empower decision makers.”³⁰ A concept of network centric warfare was introduced to the Department of Defense in the mid- to late 1990s.³¹ There are four distinct components of this approach: (1) A robustly networked force improves information sharing; (2) information sharing and collaboration enhance the quality of information and shared situational awareness; (3) shared situational awareness enables self-synchronization; and (4) the above dramatically increase mission effectiveness. The deemphasizing of traditional hierarchical command and control approaches to incident management, and the recognition that spontaneous decision making will be effective in the setting of horizontal information flow, matches well with the potential role that health care coalitions could and should play in response to an IND event.

Health care coalitions that organize to form regional networks can improve communications of resource needs and provide situational awareness. The goal of such networks will be to enhance the response regarding management of the unstructured intake of arriving patients as well as providing for the intensive medical support irradiated patients will need under such circumstances. In the first hour to hours, during which time event characterization will be important, effort will be focused on projecting the location and direction of the fallout plume and sharing this information with the public. Hours after the detonation, to the first day or days, information provided to those who require radiation screening, or more definitive medical attention, will become most important. While this information will be of significant importance in the close-in communities affected by the blast, because of the forecast population movement anticipated as occurring as a result of such an attack, the surrounding communities will play an increasingly important role in supporting the needs of this migrating population.

Those close-in communities that are geographically adjacent to the ground zero impact zone will struggle to accomplish the emergency response functions related to security, fire suppression, search and rescue, patient care delivery, and other fundamental response efforts. Those communities that are farther away from ground zero, the unaffected “collar communities,” will have an enormous responsibility to support command and control functions, both hierarchical and vertical, and to support the lost infrastructure in the affected communities. This may include not only the communications infrastructure, but much of the emergency response mechanism that may either be directly impacted by the event or consumed by the enormous response that is likely to be required. Collar-community health care coalitions may be able to broaden their network of communications capabilities, coordinating communication and allocation requests that accommodate the needs of the impact communities. Perhaps most importantly, collar-community coalitions will be required to ramp up procedures for managing the influx of surge patients (trauma, radiation, combined, non-affected but requiring “routine” emergency care, etc.) that are certain to present seeking medical care and attention. As patients, care needs become better defined, and the stratification of care is conducted along the surge capacity framework ranging from conventional surge to contingency and crisis surge responses, the outlying health care coalitions will be able to prioritize information shared with the state EOC and federal government regarding resource allocation needs. This coalition-to-coalition networking and coordinated response, as well as coalition-to-state coordination, is only possible with the development of robust, mature health care coalitions that are fully integrated partners in their community emergency response system.