If California is hit by a catastrophic event (some contend this sentence should start with "When" not "If"), the state's health care system might be better prepared to deal with it following the release last month of a comprehensive guide for hospitals, clinics and local health departments.
Billed as the first of its kind in the nation, the 1,900 page document goes into sobering detail about suspending or bending regulations and common practice after a widespread disaster such as an earthquake, bioterrorist attack or disease outbreak.
The plan specifies which patients should get priority, which patients should be put on hold. It addresses the likelihood that medical care will have to be delivered "outside of normal settings, including hallways, parking lots, gymnasiums." Plans are laid out for enlisting non-professionals to administer emergency medical support. Veterinarians may be called on to treat humans.
State officials say the $5 million plan, "Standards and Guidelines for Healthcare Surge During Emergencies," will become a model for the nation.
Nurses Aren't Convinced
"We're concerned about the assumptions that there will be inadequate resources, therefore it's OK to suspend regulations and simultaneously limit legal liability, which only exist to protect patients," said Donna Gerber, director of government relations for the California Nurses Association.
"Why not make a plan based more upon increasing resources and equipment?" Gerber asked. "California hospitals do a poor job hiring enough staff and having enough bed capacity right now every year during flu season even though it is an expected 'surge' in the need for increased services that occurs at a predictable time each year."
The plan takes into account the likelihood that the ranks of health care providers -- doctors, nurses and hospital staffs -- will be depleted. Research shows that almost half the health care workers in an area hit by a major disaster might not report to work for a variety of reasons -- their own family needs, inability to travel, illness or injury.
Mark Horton, director of the California Department of Public Health, said business-as-usual won't be possible after a major catastrophe.
"During a major disaster, the heath care system will look very different from what we are accustomed to," Horton said. "These guidelines will help communities as they plan how to sustain a functioning health care system following a catastrophic event such as a severe earthquake, bioterrorism attack or outbreak of pandemic influenza."
The Department of Public Health this week begins a series of training workshops to introduce the standards and guidelines to providers and local health departments.
Aside from the nurses association, comments "have been mostly very favorable" so far, according to department spokesperson Ken August.
'When,' Not 'If'
According to some predictions, an earthquake of catastrophic proportions is a matter of "when" in California, not "if." In the context of the government's new surge guidelines, it's "the elephant in the room" that nobody is talking about, CNA's Gerber said.
"The plan is heavily reliant upon using acute care hospitals as places for patients to go even though there are about 1,000 identified hospital buildings that are categorized to 'collapse' during a major seismic event, which is the most predictable disaster facing California," Gerber said. "It is unlikely that California will have enough hospital capacity in the region that suffers the seismic event. This seems like the elephant in the room that those planning for disaster are not identifying as a problem."
Jan Emerson, spokesperson for the California Hospital Association, said that earthquake preparedness is indeed a focal point for state and hospital officials and that new methods of evaluating seismic readiness will show many hospital buildings are safer than previously thought.
"The notion that seismic considerations are not taken into account is just ridiculous," Emerson said. "We've been dealing with it for years, and we will continue to deal with it for years to come."
Almost 1,100 hospital buildings in the state have been identified as potentially unsafe in an earthquake. The price tag for bringing them into seismic compliance is estimated at $110 billion in construction costs alone. A RAND report estimates that interest and bond costs could double that figure.
Emerson called it the most expensive unfunded mandate in the history of the state.
A new system known as HAZUS, using a complex computer program that predicts damage caused by natural disasters, was approved by state officials late last year.
"I think using this new evaluation tool, many hospital buildings will be found to be not as much at risk as previously thought," Emerson said. She estimates the number of hospital buildings needing immediate seismic upgrades will be cut by half using the new evaluation tool.
Buildings found to be at lesser risk using the new evaluation program will have until 2030 to make structural upgrades. Most hospitals needing seismic work face a deadline of 2013.
Bigger Than Seismic Issue
Emerson said the surge report goes beyond the issue of any particular hospital building's ability to withstand an earthquake. "We're not talking about normal circumstances here or even an isolated earthquake. We're talking about thousands and thousands of patients all needing help at once in what very well may be a state of chaos."
The plan is part of Gov. Arnold Schwarzenegger's (R) 2006 health care surge initiative, a $172 million project that includes creation of mobile field hospitals and stockpiling of medicine and medical equipment, such as extra hospital beds, millions of doses of antiviral medications and thousands of ventilators.
California's plan was drawn up partly in response to recent major disasters elsewhere in the country, including the terrorist attacks of 2001 and Hurricane Katrina in 2005. Nurses who worked in the Gulf Coast in Katrina's wake said the area would have been better served by more attention to health care before the hurricane hit.
Some 500 California nurses volunteered in shelters, hospitals and clinics on the Gulf Coast after Katrina came and went.
"What our volunteers saw is that the lack of health care caused by our current high number of uninsured residents due to our expensive, private insurance system means that when disaster hits, the outcomes are even more tragic because the health of the population is so neglected to begin with," Gerber said.
"For many of the RNs, it was like seeing health status of a third-world country in the U.S.," Gerber said. "Changing our system should be part of the discussion of preparing for disaster."