Healthcare/Public Health Lessons-Learned from the Puerto Rico 2017 Dual Hurricane Experience

Len Singer MD FACS

Pietro Marghella DHSc MSc MA CEM FACCP

Assumption #1

Assumption #1 Healthcare & Public Health (HPH) is one of the most critical sectors of the 16 or 17 critical infrastructures

The Healthcare and Public Health Sector is highly dependent on fellow sectors for continuity of operations and service delivery, including Communications, Emergency Services, Energy, Food and Agriculture, Information Technology, Transportation Systems, and Water and Wastewater Systems.

The Theory of Siloization Gergen & Marcus (2005) have introduced the concept of Siloization to describe the current state of preparedness of the U.S. Public Health & Medical Infrastructure - META LEADERSHIP LEADERSHIP Forging Connectivity

And the Dilemma of the Cube Further, according to Marcus, the Public Health/Medical Communities suffers the Dilemma of the Cube Peep hole B Peep hole A Peep hole A Public Health Preparedness Community Peep hole B Healthcare Delivery Community

Assumption #2

Assumption #2 Your jurisdiction may find itself on its own in your next disaster; likewise your healthcare/public health critical infrastructure.

FEMA is not a first responder Daniel Kaniewski FEMA Deputy Administrator

Assumption #3

Assumption #3 Your Department of Health is mandated (whether it admits it or not) to assuring the delivery of healthcare in times of disaster

Link people to needed health services. Acquire, allocate, and dispense resources, and enable public health workers to meet priority community health needs in the best way possible.

Local health departments play a key role in achieving national health security by preparing their communities for disasters, responding when emergencies occur, and lending support through the recovery process.

The 10 Essential Public Health Services: Monitor health status to identify and solve community health problems Diagnose and investigate health problems and health hazards in the community Inform, educate, and empower people about health issues Mobilize community partnerships and action to identify and solve health problems Develop policies and plans that support individual and community health efforts Enforce laws and regulations that protect health and ensure safety Link people to needed personal health services and assure the provision of health care when otherwise unavailable Assure competent public and personal health care workforce Evaluate effectiveness, accessibility, and quality of personal and population-based health services Research for new insights and innovative solutions to health problems

Public Health Healthcare Emergency Management?

Gov t. Public Health Healthcare Emergency Management Healthcare Private

DEFINING The IRMA and MARIA Dual Hurricanes as a Black Swan Event

Exacerbated Healthcare Crisis Dual Hurricanes Preexisting Healthcare Crisis

A. Infrastructure Challenges Shattered highway and roadways Energy supplies marginal Poor access to potable water Aging healthcare infrastructure Poor pre-hospital transport/ems with increased demand

B. Inadequate Staffing Many health care professionals have left the island before the hurricanes Potential increased demand Attention to acute emergencies has compromised availability of care for chronic patients

C. Inadequate Supplies Loss of cold chain may have compromised stocks of blood, insulin and vaccines Geographic challenges had limited delivery of supplies and meds to cities other than San Juan, especially in the rural interior Presumption of increased demand due to exacerbations of asthma, hypertension, behavioral abnormalities

STRATEGIC

(current) Private Model: healthcare functions independently of public health Mixed Model: public health assures healthcare delivery in disaster Public Model e.g. public health assumes control of regional nodes in disaster Degree of Privateness

Coalition Node Medical Reserve Corps, outside volunteers, alternate care sites Pharmacies, dialysis centers, etc. Insurance Companies, MCOs Regional Hub for Healthcare Hub Other hospitals in the region Ambulance Companies Closest medical and nursing schools Coalition Regional public health representation community providers, nursing homes

Coalition Node Medical Reserve Corps, outside volunteers, alternate care sites Pharmacies, dialysis centers, etc. Insurance Companies, MCOs Regional Hub for Healthcare Stakeholders (spokes) Other hospitals in the region Pre-hospital EMS and Ambulance Companies Closest medical and nursing schools Coalition Regional public health representation community providers, nursing homes

Coalition Node Standardization of planning and response Medical Intel/Disaster Epi (via Health Ops Center HOC) Regional Hub for Healthcare DISASTER FUNCTIONS Allocate Staff (e.g. MRCs) STAFF Manage inpatient bed resources, Dialysis, trauma beds, alternate care facilities Coalition Distribution of equipment, supplies, blood products

Coalition Node Standardization of planning and response Medical Intel/Disaster Epi (via Health Ops Center HOC) Regional Hub for Healthcare DISASTER FUNCTIONS Allocate Staff (Medical Reserve Corps) Manage inpatient bed resources, Dialysis, trauma beds, alternate care facilities Coalition Distribution of equipment, supplies, blood products STUFF

Coalition Node Standardization of planning and response Medical Intel/Disaster Epi (via Health Ops Center HOC) Regional Hub for Healthcare DISASTER FUNCTIONS Allocate Staff (Medical Reserve Corps) BEDS Manage inpatient bed resources, Dialysis, trauma beds, alternate care facilities Coalition Distribution of equipment, supplies, blood products

Coalition Node AREA COMMAND Standardization of planning and response Medical Intel/Disaster Epi (via Health Ops Center HOC) Regional Hub for Healthcare DISASTER FUNCTIONS Allocate Staff (Medical Reserve Corps) Manage inpatient bed resources, Dialysis, trauma beds, alternate care facilities Coalition Distribution of equipment, supplies, blood products

Coalition Node Standardization of planning and response MEDICAL INTEL Medical Intel/Disaster Epi (via Health Ops Center HOC) Regional Hub for Healthcare DISASTER FUNCTIONS Allocate Staff (Medical Reserve Corps) Manage inpatient bed resources, Dialysis, trauma beds, alternate care facilities Coalition Distribution of equipment, supplies, blood products

DOH Regional Node Local EOC

Tactical Tasks 1 Restructure public health preparedness for disaster: Build Regional Coalition Nodes Identify qualified Hub Hospitals Identify critical spoke hospitals Enable the coalition process Initiate and support the Region s Medical Reserve Corps Write the SOP (standard operating procedures ) manual for the regional coalition node Determine funding structure

Tactical Tasks 2 Within the Department of Health: Recruit and train state/territory/regional Healthcare IMT (HIMT) Recruit and train positions for the Regional Node Health Operations Center (HOC) - to be staffed by healthcare area command and state/territory public health personnel Write guidance on patient transfer policy Restructure State/Territorial OPS Center to focus on Medical Intel function

Proposed HIMT

Proposed HIMT Operations Section Chief Pre-Hospital Branch Blood Products Branch Pharmaceutical Distribution Branch Dialysis Branch

Proposed HIMT Service Branch Logistics Section Chief Support Branch Electricity Unit Food Unit Fuel Unit Communications Unit Water Unit IT Unit Supply Unit Transfer Unit

Tactical Tasks 3 Disaster Extension Service Create a Web site Write the curricula Deliver the coursework Train the Trainers

Boot Camp Subjects Healthcare ICS for Disasters & Catastrophic Incidents Leadership & Teaming in Disaster ESF-8 Skill set The regional Coalition Node Model Telecomm & Ham Radio skills Emergency water safety skills Emergency power assurance skills Disaster epidemiology and data collection Threat : resiliency assessment Prevention:Mitigation:Preparedness TRIAD

Tactical Tasks 5 State/Territorial Department of Health Commonwealth Coalition Summit Bring together the proposed hub hospitals Socialize the coalition concept Define the incentives

Hazards are Sure to Occur as surely as sun will come up tomorrow. The clock is ticking we just don t know what time it is.

Hazards are Sure to Occur Yes, we do. It s 8:45 AM.

Notable Quotables There are risks and costs to a program of action, but they are far less than the long-range risks and costs of comfortable inaction. John F. Kennedy I d rather prepare our citizens than mourn them. Ronald W. Reagan

Thank You for Your Attention! Questions? Comments? Suggestions for how to fix all of this?? Contact Information: Dr. Pietro D. Marghella The George Washington University Milkin Institute School of Public Health Email: hsmlpdm@gwu.edu Phone: (571) 331-2598