Public Health Preparedness: Are Public Health Systems Ready for a Disaster?

A glance at the newspapers reminds us of the many reasons to examine the preparedness of our health care system: the arrival of a new hurricane season, the fear of bioterrorism, and the potential for an avian flu pandemic, just to name a few. In these and other crises, hospital emergency departments (EDs) are on the frontlines of disaster response. As such, the needs of hospital EDs must be integrated into public health planning. But as a battle hospital relies on support and supplies from headquarters, EDs rely on the public health systems and public health departments, which are integral in managing and responding to situations on a community level. Strengthening this essential continuum of care between community systems and frontline treatment centers has been identified as a strategic goal by the Department of Health and Human Services, which included enhancing the ability of the nation's health care system to effectively respond to bioterrorism and other public health challenges as part of its five year objectives from FY 2004-2009.1

Recent reports have further demonstrated this pressing need. The Institute of Medicine (IOM) recently released a series of reports on the state of the nation's emergency rooms that question the ability of our health system to deal with major disasters. The reports found that many emergency departments and trauma centers are overcrowded. Between 1993 and 2003, the number of emergency visits grew by 27 percent, from 90 million to 114 million. Yet, over the same period of time, there has been a decrease of 425 EDs and 198,000 hospital beds. Furthermore, the emergency care system is inadequately prepared to handle a major disaster; the overcrowding of EDs has left little surge capacity for a major event, whether it is a natural disaster, disease outbreak, or terrorist attack. Additionally, many emergency medical services ( EMS ) personnel lack the necessary equipment, funds, and training to deal with these events.2

Not only did these reports find the emergency care system to be "overburdened and underfunded," it also found it to be "highly fragmented." This fragmentation hampers our ability to respond to disasters at the community level. Cities and regions are often served by multiple 911 call centers and EMS services are not effectively coordinated with EDs and trauma centers; as a result, the regional flow of patients is poorly managed. The reports further found that there is ineffective communication between EMS and public health departments with the two often operating on different radio frequencies and with different procedures in emergencies.3

As research and analysis of these shortcomings in our nation's preparedness systems is presented, recommendations on strengthening our capabilities have begun to emerge. First, the IOM calls for action to relieve overcrowding and other detrimental practices such as boarding of patients and ambulance diversion. The expansion of emergency departments to accommodate these patients and potentially more in case of a disaster is vital. In addition to expansion, innovative programs on a local level that address admissions, discharges, and patient movement within the hospital have shown promise.4 Second, the IOM reports recommend the creation of a "coordinated, regionalized, accountable system," in order to better ensure the best emergency services for the patients. They also call for the creation of national performance standards by the federal government in different areas of emergency response and care.

A successful disaster response will require this system to rely on strengthened relationships between public health departments and the clinician community, in areas of information systems and communication networks, and in infrastructure and personnel.5 New technologies will enable these networks to function smoothly, yet the lessons of Hurricane Katrina remind us that disasters can sometime disrupt the electronic systems we rely on daily, so better coordination among professionals in the medical and public health communities is important. Hospital and health department preparedness plans must be better coordinated in all facets.6 Finally, health departments must better organize and adapt in order to respond to a new expanded role in emergency preparedness, while not losing sight of more traditional public health functions.7

These recommendations lay out general areas where gaps in our nation's preparedness need solutions. As some of the cited publications suggest, the answers lie both in new ideas, as well as in evaluating previous efforts to determine what solutions work best.

Current HCFO grantee Michael Stoto, Ph.D., of RAND , is conducting a series of comparative studies examining the regionalization of public health systems-the organization and development of such systems, as well as the impact they would have on public health preparedness.

Another HCFO sponsored project conducted by Gloria Bazzoli, Ph.D., examined organization and performance of trauma systems. Among its findings was the identification of common factors that were found to be important in the development of comprehensive trauma systems, such as broad-based participation of key stakeholders, patient and resourceful local trauma leaders, events that catalyzed change, and funding for trauma programs.

The integration and coordination of EDs and public health systems remains important to our future disaster response and preparedness planning. HCFO funded research will continue to inform this policy debate.

HCFO Funded Research

Title: Measuring the Value of Public Health Systems
Institution: The University of Michigan
Time: March 2006-February 2007
Principal Investigator: Peter Jacobson, J.D.

How can the value of governmental public health systems (GPHSs) be defined and measured? The GPHS is a state and local apparatus designed to assess and respond to threats to the public's health through population-based and individual health services. The researchers will examine how other public or quasi-public entities define and measure value; the methodologies used to measure value; the criteria for determining and measuring value; and how measuring the value of these services will affect other important dimensions of public health systems, such as accountability. The objective of this study is to develop ways for policymakers to incorporate value measures for governmental public health system activities into resource allocation decisions.

Title: Structural Capacities, Processes, and Performance of Essential Public Health Services by Small Local Public Health Systems
Institution: University of Wisconsin
Time: February 2006-January 2008
Principal Investigator: Susan Zahner, Ph.D.

What factors influence the performance of small local public health agencies (LPHA) in Wisconsin ? The researchers will identify key factors by determining the contributions of specific structural capacities and processes in providing three public health services: 1) monitoring health status, 2) mobilizing community partnerships, and 3) developing policies and plans. The objective of the study is to gain insight into specific factors that can improve the quality of small local public health systems in order to assist policymakers and administrators with targeting resources and technical assistance.

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Title: Causes and Consequences of Change in Local Public Health Spending
Institution: University of Arkansas for Medical Sciences
Time: March 2006-February 2007
Principal Investigator: Glenn Mays, Ph.D., M.P.H.

The researchers will examine the causes and consequences of changes in local public health agency spending. In particular, they will address the following questions: 1) How have local health spending levels and funding sources changed over the past decade; 2) How have disparities in spending levels changed among communities defined by population size, rural/urban location, socioeconomic and racial/ethnic composition, and structural characteristics of the public health system; 3) To what extent have economic, demographic, and policy-related factors precipitated change in local public health spending levels and funding sources over this period; and, 4) To what extent are changes in local public health spending associated with changes in local population health status and disease burden? The objective of the study is to assist policymakers at the federal, state, and local levels in crafting desirable strategies for funding local public health services and to provide insight into the effects of changes in spending on population health, correction of existing gaps, and disparities in the allocation of resources.

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Title: Regionalization in Local Public Health Systems: Variation in Rationale, Implementation, and Impact of Public Health Preparedness
Institution: RAND
Time: February 2006-January 2007
Principal Investigator: Michael Stoto, Ph.D.

What is the effect of regionalization of public health structures? The researchers will use four comparative case studies to 1) document various rationales for creating regional public health structures; 2) understand how these structures have been organized, implemented, and governed; and 3) assess the current and likely impact of regional structures on public health preparedness and public health systems more generally. The case studies will address coordination, standardization, and developing regional capacity. The objective of the study is to provide a better understanding of the regionalization of pubic health systems in order to inform the many state and local health departments currently developing regional structures.

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Title: Trauma System Structure and Performance
Institution: Hospital Research and Educational Trust
Time: September 1991 - August 1994
Principal Investigator: Gloria J. Bazzoli, Ph.D.

How well do regionalized trauma systems work and what affects their performance? This study explored the impact of the structure and organization of regionalized trauma care systems on their effectiveness, measured by patterns of hospital utilization, trauma mortality, financing, and stability. The project surveyed all existing trauma systems in the United States to identify key structural features, conduct case studies in areas with trauma systems and areas without such systems to examine the reasons behind the development of particular structures, and conduct descriptive analyses to assess empirically the relationship between structure and performance. The objective of the study was to provide information to state and local policymakers, hospitals, physicians, and other community leaders to help them develop more effective trauma systems, which will be particularly timely in light of legislation passed in 1990 that provided federal funding for regionalized trauma systems.

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1. United States Department of Health and Human Services. HHS Strategic Goals and Objectives, FY 2004-2009.
2. Institute of Medicine. The Future of Emergency Care: Key Findings and Recommendations. June 2006.
3. Ibid
4. Levine, Susan and F. Kunkle. ERs Swamped Despite New Beds and Strategies. The Washington Post. June 18, 2006.
5. Lurie, Nicole. Public Health Preparedness in the 21 st Century. The Rand Corporation. March 28, 2006. http://www.rand.org/pubs/testimonies/2006/RAND_CT257.pdf
6. Davis et al. Public Health Preparedness - Integrating Public Health and Preparedness Programs. The Rand Corporation. 2006.
7. Wasserman et al. Organizing State and Local Health Departments for Public Health Preparedness. The Rand Corporation. 2006.