March 27, 2003 -- Too few beds in Bay Area makes disaster and bioterror planning problematic


Contra Costa Times, Thu, Mar. 20, 2003

Funding lack at hospitals raises risks By Judy Silber

Source: Robin Gordon, Eden Medical Center

The Bay Area's hospitals are readier than ever to handle a terrorist
attack, but delays in funding and a chronic shortage of beds leave
open the question of whether they are ready enough.

The region's health care system has had extensive experience with
natural disasters and industrial accidents, such as earthquakes and
refinery explosions.

But Sept. 11 and the subsequent anthrax attacks left hospitals
scrambling to prepare for a nuclear, chemical or biological assault,
which would stress the system in ways vastly different from quakes and
fires. That planning has taken on even more importance as the nation
has prepared for war with Iraq and possible terrorist retaliation at
home.

Emergency planners have meticulously updated their disaster plans,
preparing for scenarios involving biological or chemical weapons.
Still, California's health officials say they worry that the system
can't handle a severe flu epidemic, let alone a terrorist attack
causing mass casualties.

Hospitals say they would like to train more people and purchase more
supplies, but complain they have received little government funding.
They also worry that their communications systems and equipment are
not compatible with other hospitals, which could lead to critical
delays in an emergency.

So ask any emergency planner if we're ready and they will give you an
answer that goes something like this:

"It's not a question that you could ask anyone in my line of work and
get an answer, 'Oh, yeah, that's right where we need to be,'" said
Robin Gordon, chairman of Eden Medical Center's emergency preparedness
committee.

The events of the last year and a half forced the medical community to
confront a new world. Hospitals and public health agencies stopped
debating whether an attack could happen here and started preparing for
one.

Having been near the bottom of hospitals' risk assessment lists,
bioterrorism and chemical and radiological contamination quickly rose
to the top. Hospitals and counties developed detailed plans for
treating victims of large-scale attacks. They purchased protective
equipment and trained staff to handle chemical and radiological
decontamination. They inundated physicians with information about
biological threats. Statewide drills featured weapons of mass
destruction rather than earthquakes or fires.

Despite the additional preparation, it's clear there are still
vulnerabilities.

"How prepared are we?" asked Dr. Robert Benjamin, Alameda County's
interim public health officer. "I don't think we're very well
prepared."

To fill some gaps, in December 2001 Benjamin began putting together a
bioterrorism and disaster-response plan for the county. Naively, he
admits, he thought the project would take only a few months. It
stretched out more than a year, producing a 400-page behemoth with the
input of more than 70 hospital and county representatives. The plan
details emergency procedures down to the number of chairs, tables and
extension cords required for a mass vaccination should a smallpox
outbreak occur.

However, Benjamin notes there's still more to do. The plan still needs
testing, for instance. Perhaps more important, Alameda and other
counties around the state may have one unfixable flaw: not enough
hospital beds. Whereas Alameda County once had 22 hospitals, it now
has 14 due to a decade of closures, mergers and consolidations. Contra
Costa County has only eight, compared with 10 a few years ago. Four
trauma centers must serve the two counties, an area of 1,458 square
miles and more than 2 million people.

A disaster causing many casualties would overwhelm most hospitals,
says Christopher Amy, facilities risk manager and safety officer at
Children's Hospital Oakland. Children's already is nearly full,
despite a mild cold and flu season, he said. Yet the hospital is
gradually losing, not gaining beds. A large-scale emergency with many
casualties would quickly tax the hospital's resources, he said.

In addition, most hospitals don't own the tents or cots needed to
quickly expand capacity in an emergency. They've made arrangements to
rent, but hospital emergency coordinators worry about accessibility
during a true crisis.

In 2002, the U.S. Department of Health and Human Services designated
$135 million for hospital equipment and training, but coordinators say
they've yet to see that money. They grumble that the government has
doled out far more to their emergency counterparts -- police, fire and
public health.

"First responders and the county are getting money and hospitals
aren't," said Caryn Thornburg, emergency management and hazardous
materials coordinator for ValleyCare Health System in Pleasanton and
Livermore. "We need to work on sharing the wealth."

The money is on its way, said Cheryl Starling, coordinator of
California's bioterrorism preparedness program. The state expects more
than $9 million of the $135 million grant from the government.
Hospitals will start receiving the money as soon as the governor
approves a draft spending plan for the 2002 fiscal year, as early as
April, she said. Another $20 million to $40 million is expected for
the 2003 fiscal year.

Starling would not comment on where that money would go. But other
committee members said it will likely address a lack of compatibility
among hospitals' communication systems and equipment. For example,
hospitals within Contra Costa and Alameda counties use a computer
system known as ReddiNet to assess bed availability. Other counties
use other systems. And some hospitals remain old-fashioned, relying on
phones and radios instead of high-tech gear.

"We need to get these systems to speak with each other, and in some
cases, to get them in place," said Dr. William Walker, a committee
member and Contra Costa County's public health officer. Being able to
count beds and divert patients to hospitals with space could become
critical in a time of crisis, he said.

Similarly, consistency in equipment will allow hospitals to borrow
from one another in a pinch. The federal dollars may also help
hospitals and the state purchase additional pharmaceuticals and
supplies to supplement otherwise minimal stocks.

Still, hospitals have come a long way in the last 18 months. Overall
emergency planning efforts have intensified, especially for chemical,
biological or nuclear attacks.

"All of us are looking to upgrade our plans and policies," said
ValleyCare's Thornburg, whose job as a disaster planner went from part
to full time in August.

In the past, hospitals assumed that fire departments would respond
first to most chemical or radiation incidents. But that thinking has
changed. Victims of a chemical attack may simply drive to the nearest
hospital, bypassing paramedics. Hospitals are training decontamination
teams for round-the-clock coverage should they need it. Some, like
Eden Medical Center in Castro Valley, are looking to build indoor
decontamination rooms, to replace temporary outdoor showers where it's
hard to collect contaminated runoff.

At Kaiser Permanente, a committee meets weekly to discuss threats and
the appropriate guidance for Kaiser's facilities. Of late,
conversations have centered around smallpox. But discussions can
include a range of topics including chemical and nuclear terrorism.

Kaiser formed its first bioterrorism team back in 1999 in response to
a government warning on Y2K threats. But at the time, most people
doubted they'd ever need a plan, said Skip Skivington, Kaiser's
national director of health care continuity management. Kaiser ended
up using the plan to treat anthrax victims who ended up at Kaiser
hospitals.

Communications among hospitals and other emergency agencies have also
improved. Before Sept. 11, hospitals acted as stand-alone entities,
rarely consulting with one another.

Alameda's hospital emergency coordinators now meet quarterly to
compare notes on disaster planning. There's more contact with public
health, police and fire departments. Emergency counterparts have
gotten to know one another personally. And they're making sure they
understand one another's plans.

"It was finally understood in a very real sense that we're not solos,
that we can't work independently," said Amy Nichols, manager of
infection control at Alta Bates Summit Medical Center in Berkeley and
Oakland. "We really have to depend on each other to have a united
response to anything that occurs."

THE RESPONSE

Here's how the health care system would respond to a terrorist
attack:

1. A 911 dispatcher contacts the county emergency operations
center (in Dublin in Alameda County and Martinez in Contra Costa
County). The dispatcher's call, or a call from a hospital in the midst
of a disaster, activates the center. County staff who will coordinate
communications between emergency responders and the hospitals are
notified.

2. A phone-tree system to bring hospital staff to the hospital
begins.

3. Ambulance, fire and police arrive at the scene, setting up a
triage point. They report the number of victims and the extent of
their injuries to the emergency operations center. A computer
system called ReddiNet assesses hospital bed availability in the two
counties. The operations center tells people at the scene where to
send victims.

4. The first choice of communications between hospitals and the
operation center is by phone. If phone lines are down, 800 megahertz
radios are used. Ham radios also serve as backups. Another radio
system called Mednet allows the center and hospitals to communicate
with ambulances.

5. The operations center informs the hospital of any new
information at the scene. Hospital staff can also listen in on radio
communications to assess whether specialty staff such as a trauma unit
are needed. If the hospital is full but beds are needed for victims,
it will discharge patients who can go home. If the hospital needs
supplies or pharmaceuticals, it contacts vendors who have previously
agreed to make available supplies in the event of an emergency. It may
also request supplies from other area hospitals.

6. In the event that the county requires additional supplies or
beds, the operations center contacts the state emergency operations
center, which will contact a larger geographic region, if necessary. A
national stockpile can also deliver pharmaceuticals and supplies
within 24 hours.