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Homeland Security Focus
Areas
Medical Care Delivery
HHS Grants Still Shortchange Emergency Medical Preparedness |
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by Anthony L. Kimery |
Tuesday, 10 June 2008 |
'This isn’t about trauma centers'
Last week, Health and Human Services (HHS) Secretary Mike Leavitt announced that the department has made available nearly $1.1 billion to continue assisting public health departments, hospitals, and other health care organizations to strengthen their ability to respond to public health and medical emergencies as a result of a terrorism attack or naturally occurring event.
But medical emergency preparedness authorities say the grants aren’t targeted enough at helping hospitals to specifically prepare for catastrophic mass casualty events, especially preparations for surge, an issue HSToday.us recently reported on.
Indeed. Responding to recent congressional hearings on how pending cuts in Medicaid payments to hospitals will exacerbate many hospitals’ already deteriorating financial bottomlines and that this erosion is directly impacting trauma and emergency care, Leavitt conceded that hospital surge capacity is not where HHS would like it to be. Nevertheless, he said, the impending regulations are necessary to make sure states are paying their fair share.
“Otherwise, we’re not being a wise steward of limited Medicaid funds,” Leavitt said, stressing that hospitals have been taking federal dollars for patient care and putting them in general funds. “This isn’t about trauma centers, it’s about the relationship between the states and the national government,” he said.
Leavitt said If Congress should find that there is a need for more money to help hospitals improve their surge capacity, then HHS can direct more funds to the hospitals. “Medicaid was intended to be for people, not for institutions,” he said.
House Oversight and Government Reform Committee Chairman Henry Waxman said that the “tiny grants” to hospitals have not been enough to improve surge capacity.
HSToday.us reported last month that there is abundant evidence of the crisis in trauma and emergency medical care. In addition, a recent Centers for Disease Control and Prevention (CDC)-funded study found serious problems in trauma care and hospital surge preparedness, as did an HHS study in 2004.
Furthermore, HHS has repeatedly noted the importance of adequate surge capacity in its pandemic preparedness planning.
Legislation has been introduced in both the House and Senate that directly addresses the nation’s trauma and emergency medical care system.
Leavitt said when announcing the grants that “states and local communities need to be supported because they are the front lines of response in a health emergency. These funds will continue to enhance community readiness by increasing the capabilities of health departments, hospitals, and health care delivery systems to respond to any public health emergency.”
The HHS funding is awarded via two separate but interrelated cooperative agreements:
HHS’ CDC is providing a total of $704.8 million in funding to health departments in states, territories, and metro areas of New York City, Chicago, Los Angeles County and Washington, DC, through the Public Health Emergency Preparedness (PHEP) cooperative agreement.
The HHS Assistant Secretary for Preparedness and Response (ASPR) is also awarding $398 million through the Hospital Preparedness Program (HPP)
These CDC grants are to be used to:
- Integrate public health and public and private medical capabilities with other first responder systems;
- Address the public health and medical needs of at-risk individuals (such as children, or people with chronic medical disorders) in the event of a public health emergency; and
Assure coordination among state, local, and tribal planning, preparedness, and response activities.
The ASPR-awarded funds are to be used to finalize development or improve:
- Interoperable communication systems;
- Systems to track available hospital beds;
- Advance registration of volunteer health professionals;
- Processes for hospital evacuations or sheltering-in-place;
- Processes for fatality management, and
- Strengthening health care partnerships at the community level.
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HSToday
Trauma Care Crisis, Lack of Surge Capacity Continues to Worsen |
by Anthony L. Kimery |
Tuesday, 13 May 2008 |
'The number of patients at Washington Hospital Center was 286 percent of the number of treatment spaces'
The Democratic staff of the House Committee on Oversight and Government Reform last week released a report that concluded that trauma centers in major cities at risk to catastrophic terrorist attacks do not have the capacity to handle the numbers of casualties that can be expected to seek emergency care as a result of a 9/11-scale attack.
The report, “Hospital Emergency Surge Capacity: Not Ready for the ‘Predictable Surprise,’” was based on a survey of Level I trauma centers in seven major cities designed to assess whether they have the capacity – known as “surge” - to respond to the level of casualties that resulted from the March 11, 2004 attack on commuter trains in Madrid. Those bombings killed 177 and injured more than 2,000. Nearly one thousand patients were transported to 15 hospitals. In less than three hours, 270 patients arrived at a single hospital in Madrid.
According to the Centers on Disease Control and Prevention (CDC), a terrorist bombing in the United States like the one in Madrid is a “predictable surprise” and an appropriate baseline for assessing whether the emergency care system in the US is prepared to respond to a terrorist attack.
The survey included five of the cities considered at highest risk of a terrorist strike: New York City, Los Angeles, Washington, DC, Chicago, and Houston. It also included Denver and Minneapolis.
Although the report noted that “the Level I trauma centers surveyed are not the only providers of emergency care in the seven cities, they are the hospitals that can provide the highest levels of injury care and would be the preferred destinations for casualties in the event of a terrorist attack involving conventional explosives. Severely injured patients treated at Level I trauma centers have a significantly lower risk of death than patients treated at hospitals that are not trauma centers.”
The committees’ “snapshots of trauma centers’” surge capacity took place on Tuesday, March 25 at 4:30 PM local time in each of the seven cities. It was designed to determine the real-time capacity of the emergency rooms at the Level I trauma centers to absorb a sudden influx from a mass casualty event. Thirty-four of the 41 Level I trauma centers in these cities participated.
What the committee’s investigators found was not reassuring given it’s now almost seven years after 9/11 and billions have been spent to ostensibly prepare for another calamitous attack.
“The results of the survey show that none of the hospitals surveyed in the seven cities had sufficient emergency care capacity to respond to an attack generating the number of casualties that occurred in Madrid,” the report stated. “The Level I trauma centers surveyed had no room in their emergency rooms to treat a sudden influx of victims. They had virtually no free intensive care unit beds within their hospital complex. And they did not have enough regular inpatient beds to handle the less severely injured victims. The shortage of capacity was particularly acute in Los Angeles and Washington, DC.”
The paucity of capacity in the nation’s capital was the worst uncovered by the survey, although Washington, DC is classified by DHS as a “high threat, high density urban area’ at the “highest risk” to an attack.
The survey found that both Level I trauma centers in the Capital were operating, on average, at 214 percent of capacity.
“In total, the emergency rooms in Level I trauma centers in Washington, DC had zero available treatment spaces to address the demands faced by one hospital in Madrid on the day of the [commuter train bombings there]. Both centers were already using overflow spaces.”
Continuing, the survey reported that “the number of patients at Washington Hospital Center was 286 percent of the number of treatment spaces,” and emphasized that “no other emergency room in the survey across the country had a higher number of patients in relation to the number of standard treatment spaces.”
On average, the Level I trauma centers in Washington, DC have only 24 surge capacity beds available. For the Capital regional area, authorities have estimated that there may be at best surge capacity for 400 to 500.
Other notable findings of the survey were:
- · More than half of the emergency rooms in the Level I trauma centers surveyed were operating above capacity.
- · The total number of available emergency room treatment spaces in each of the seven cities was less than the number treated at a single Madrid hospital.
- · In Los Angeles, three of the five hospitals surveyed were on diversion.
- · In Washington, D.C., there were no available spaces in the emergency rooms of the two Level I trauma centers surveyed.
- · None of the Level I trauma centers surveyed had enough critical care capacity available for seriously injured casualties from a Madrid event.
- · None of the Level I trauma centers surveyed had a sufficient number of regular inpatient beds available to absorb the casualties from a Madrid event.
A more in-depth examination of the crisis in trauma care and surge capacity in the US begins with Part I of a new Kimery Report series.
HSToday first reported on the crisis in trauma care in the premier May 2004 edition. |
President's FY '09 Budget Slashes Hospital Preparedness Funding |
by Anthony L. Kimery |
Tuesday, 11 March 2008 |
'This is a wholly inadequate level of funding'
The National Foundation for Trauma Care (NFTC) and other emergency medical authorities are calling for Congress to restore funding for the Hospital Preparedness Program which President Bush’s Fiscal Year 2009 budget would substantially cut. This despite federal and non-government organization reports showing that the nation’s emergency medical infrastructure is far from being adequately prepared for a catastrophic terrorist attack or natural disaster, like an influenza pandemic.
NFTC is urging Congress to restore funding in the Congressional Budget Resolution and in the FY 2009 appropriations bill for the Department of Health & Human Services.
The program was authorized to be funded at $474 million in FY 2007 and at “such sums as may be necessary” for FY 2008-20012.
In FY 2007, the program was funded at $474 million and this amount was reduced to $423 million in FY 2008 as a result of budget pressures.
For FY 2009, the White House requested only $361 million for the program – a reduction of more than $61 million from the Fiscal Year 2008 level.
At this level of funding, NFTC said, there will not be enough money to provide a full year of support for the basic states grants program and no funding would be provided to the partnership program.
“This is a wholly inadequate level of funding that will damage the effectiveness of this program and undermine continued progress in improving surge capacity and other aspects of preparedness for mass casualty events,” NFTC said last week at its annual executive leadership meeting. |
chicagotribune.com
FDA Approves New Smallpox Vaccine
By JOHN HEILPRIN
Associated Press Writer
11:07 PM CDT, September 1, 2007
WASHINGTON
The approval of a new vaccine against smallpox was announced Saturday by the Food and Drug Administration, which says the shots could be made quickly if the virtually extinct virus reappears.
The vaccine, ACAM2000, is intended to innoculate people at high risk of exposure to smallpox, a highly contagious disease. The FDA said the vaccine also could be used to protect individuals and populations during a bioterrorist attack.
"The licensure of ACAM2000 supplements our current supply of smallpox vaccine, meaning we are more prepared to protect the population should the virus ever be used as a weapon," said Dr. Jesse L. Goodman, director of FDA's Center for Biologics Evaluation and Research.
Goodman said the vaccine is made using modern cell culture technology that would allow for speedy manufacturing if large quantities were needed quickly.
ACAM2000 is made by Acambis Inc. of Cambridge, England and Cambridge, Mass. The federal Centers for Disease Control and Prevention already has stockpiled 192.5 million doses of the vaccine.
The U.S. ended routine vaccination against smallpox in 1971, and world health authorities declared the disease eradicated from the wild in 1980. The last known case was reported in Somalia in 1977.
But after the terrorist attacks of Sept. 11, 2001, concern arose that smallpox and other infections could be engineered as weapons. That led to the stockpiling of certain vaccines in case they ever are needed -- and to vaccinate some military personnel and health care workers.
Only two approved U.S. and Russian labs keep known stockpiles of smallpox, which the CDC considers among the greatest potential threats to public health.
"Smallpox could be a particularly dangerous biological threat to us that would kill or debilitate a high percentage of the population," said Dr. W. Craig Vanderwagen, a rear admiral and assistant secretary for preparedness and response at the Department of Health and Human Services.
Smallpox is caused by the variola virus, which spreads through close contact with infected individuals or contaminated objects. There is no FDA-approved treatment for it.
The new vaccine is derived from the nation's old smallpox vaccine, called Dryvax, which is no longer made, although there are leftover supplies. ACAM2000 is made using a pox virus called vaccinia, which is related to but different from the virus that causes smallpox.
It contains live vaccinia virus, the FDA said, and works by causing a mild infection that stimulates an immune response that effectively protects against smallpox without actually causing the disease.
NYTimes.com
August 28, 2007
Not a Game: Simulation to Lessen War Trauma
By AMANDA SCHAFFER
The sun shines on an empty Iraqi street. A Blackhawk helicopter circles overhead. The aromas of spices from a market fill the air.
Suddenly, insurgents hiding on a roof launch a rocket-propelled grenade. The ground shakes violently and plumes of black smoke cloud your vision.
Those images, produced when a person puts on a headset, are at the heart of Virtual Iraq, a simulation created to treat Iraq war veterans suffering from post-traumatic stress disorder.
By repeatedly encountering sights, sounds, smells and rumblings that evoke painful memories, experts say, veterans with the disorder can begin to reprocess traumatic events and become desensitized to them, perhaps suffering fewer side effects like insomnia, nightmares and flashbacks.
The simulation is available to a small number of patients at sites including the Veterans Administration Medical Center in Manhattan, the Naval Medical Center in San Diego, the Emory University School of Medicine in Atlanta and Walter Reed Army Medical Center in Washington.
So-called exposure therapy, in which patients are asked to confront memories of a trauma by imagining and recounting it in painstaking detail, has long been a first-line psychological treatment for post-traumatic stress disorder. But the bells and whistles of virtual reality may make exposure therapy more effective, said Michael Kramer, a clinical psychologist at the Veterans Administration hospital in Manhattan who is overseeing the introduction of Virtual Iraq there.
“One of the hallmarks of P.T.S.D. is avoidance,” Dr. Kramer said. “Patients spend an awful lot of time and energy trying not to think about it or talk about it. But behaviorally, avoidance is what keeps the trauma alive.
“With virtual reality, we can put them back in the moment. And we can do it in a gradual, controlled way.”
Virtual Iraq features two scenarios. In one, patients navigate the streets of a generic Iraqi city, walking past buildings, cars, civilians and markets. With the touch of a therapist’s keypad, a little boy might appear on a street corner and wave, apparently in friendship, or a man might stumble down the middle of the street calling for help, a sight that provokes anxiety in some veterans who have come to fear ruses.
In the other scene, veterans ride in a Humvee. Other vehicles might slow down in front of them, and strangers might open fire. Enemy combatants might appear under bridges. Objects dotting the roadside might explode as the Humvee passes.
The patient cannot shoot back at the insurgents and also cannot die or be wounded in the simulation.
In choosing which stimuli to introduce, the therapist’s goal is to evoke the conditions present when specific traumatic events occurred, as accurately as the simulation will allow. Smells like spices, burning garbage or body odor can be emitted in four-second puffs. And the scene can be set to day or night, sun or fog or even a sandstorm.
Given the power of traumatic memories, Dr. Kramer said, it is important “to go at a pace that the veteran can tolerate, so that he isn’t overwhelmed,” and he starts to realize that the memories cannot harm him.
One risk of introducing potent material too fast is that a veteran could become retraumatized and perhaps unwilling to continue other kinds of therapy, as well.
Not all patients with the stress disorder are likely to benefit from this therapy. Veterans who lack basic coping mechanisms, are actively having flashbacks or who have unaddressed problems with substance abuse should probably not enter the simulator, Dr. Kramer said.
Dr. Albert Rizzo, the director of the Virtual Environments Lab at the University of Southern California who helped develop the simulator, said, “It’s a hard treatment for a very hard problem.”
Dr. Rizzo first created a simulation for Iraq veterans with the disorder in 2003, by modifying the Xbox game Full Spectrum Warrior. In 2004, he and Ken Graap, president and chief executive of Virtually Better in Decatur, Ga., received financing from the Office of Naval Research to develop the current simulation, with extensive feedback from veterans and active-duty members of the military.
Virtually Better also offers a Virtual Vietnam, as well as programs to address fear of heights and flying, social phobias and addictive behaviors.
Exposure therapy may not be enough for veterans with complicated symptoms resulting from chronic stress and multiple traumatic episodes, said Dr. Rachel Yehuda, director of the post-traumatic stress disorder program at the James J. Peters Department of Veterans Affairs Medical Center in the Bronx.
“I don’t believe,” she said, “that any study of exposure therapy for combat-related P.T.S.D. has shown a clinically significant improvement” in more than half the patients.
“While I would offer it to a veteran in a heartbeat, I would be prepared for the fact that it might have to be supplemented with other forms of assistance” like medication and social services, she said.
“If we’re too enthusiastic,” Dr. Yehuda added, “then people may expect veterans to be cured after 12 weeks, and it just doesn’t work that way.”
Hunter Hoffman, a cognitive psychologist at the University of Washington in Seattle, said: “With the growing ranks of Iraq war veterans who have developed P.T.S.D., now is the time for them to receive effective treatment, not 20 years from now.
“We know from Vietnam that for most patients diagnosed with P.T.S.D., these problems don’t just go away over time.”
Health Study Uses Data from Global War on Terrorism
By Gerry J. Gilmore
American Forces Press Service
WASHINGTON, May 29, 2007 – When a landmark Defense Department-sponsored health study was launched six years ago, one of its goals was to evaluate the impact of future deployments on long-term health. The investigators did not know how timely the project would be.
Today, the Millennium Cohort Study has enrolled tens of thousands of participants who have deployed in support of the global war on terrorism, said Navy Cmdr. (Dr.) Margaret Ryan, the study's principal investigator and director of the Defense Department Center for Deployment Health Research, part of the Naval Health Research Center, in San Diego.
The study was designed in the late 1990s "in the wake of the first Gulf War to answer some of the most difficult questions that couldn't really be answered retrospectively after that conflict," Ryan said.
The joint-service study was established to evaluate the health risks of military deployments, occupational exposures, and general military service, Ryan explained, noting that about 108,000 servicemembers have signed up to take part since program enrollment began in July 2001.
Participants' health is evaluated over a 21-year period, Ryan said, noting the size of the cohort -- the group participating in the study – likely will total more than 147,000 people.
"About 40 percent of our cohort has deployed to one of the more recent operations, either in Iraq or Afghanistan or surrounding regions, in support of the global war on terrorism," Ryan said.
Involvement in the study is voluntary, and participants are selected randomly, Ryan said. All information is secure and safeguarded, she added.
Participants report their health status every three years and can fill out either paper or online surveys, Ryan said.
"We do strongly encourage people to use the online option," Ryan said. "It's a very secure way to transmit information."
Dr. Tyler C. Smith will replace Ryan as the study's principal investigator later this year, as the Navy physician is slated to take a new duty assignment at Camp Pendleton, Calif.
The study is providing valuable data that will help military epidemiologists understand possible cause-and-effect relationships between combat-zone deployments and problems such as post-traumatic stress disorder, Smith said
"We have the ability to look at a large group of individuals who were deployed and not deployed," Smith said. "And we can see what factors predict new-onset PTSD, and how PTSD evolves over time. That's what we've been focusing on."
Evaluating the incidence of PTSD among servicemembers wasn't possible until recently, "simply because we didn't have a cohort in place like this that's large and population-based," Smith explained.
"So we're learning things that we really haven't been able to investigate in the past," he said.
Two picked to study troops’care
Ohio senator suggests that Bush should ask John Glenn, too
Wednesday, March 07, 2007
Josh White
THE WASHINGTON POST
WASHINGTON — President Bush named former Sen. Bob Dole and former Health and Human Services Secretary Donna Shalala yesterday to lead a bipartisan commission examining the care America’s wounded troops receive after they return from the battlefield.
The commission will be one more among several high-level reviews and investigations spawned by recent revelations of squalor and bureaucratic woes facing veterans at Walter Reed Army Medical Center.
The commission will look at the treatment U.S. troops receive from the time they leave foreign battlefields through their return to civilian life.
Sen. Sherrod Brown, D-Ohio, told President Bush yesterday that he has just the right person to serve on the commission: Ohioan John Glenn.
The former Marine pilot, astronaut and Democratic senator is "uniquely suited to serve on the commission" and a "trusted national icon with immense credibility," Brown wrote in a letter to the president.
Glenn said yesterday that as long as the commission is charged with taking a broad look at the nation’s system for caring for wounded soldiers, he would be happy to take the job.
"It would be worthwhile if they get a good group together and want to look at the whole medical system," Glenn said. "We obviously want to see everyone come back and get the finest treatment they deserve."
Bush announced that the Veterans Affairs secretary will lead a task force to deal with the immediate shortcomings in care for Iraq and Afghanistan veterans.
"We have a moral obligation to provide the best possible care and treatment to the men and women who have served our country," Bush told war veterans in Washington.
Bush again said the conditions at Walter Reed described in a series of Washington Post stories are troubling and that the situation is unacceptable.
As they opened a hearing on Walter Reed, members of the Senate Armed Services Committee criticized Army and Defense Department leaders who apparently were unaware of systemic problems in outpatient care despite multiple warnings.
Echoing what members of a House committee said on Monday during a hearing at Walter Reed, senators said that they think problems such as mold and rodents at the medical center’s Building 18 indicate larger issues with leadership and a stifling bureaucracy.
"Good leadership should have taken these steps long ago," said Sen. Carl Levin, D-Mich., the committee’s chairman.
Walter Reed’s commander, Maj. Gen. George Weightman, and Army Secretary Francis Harvey both have lost their jobs.
Yesterday, a few lawmakers asked whether the Army’s surgeon general, Lt. Gen. Kevin Kiley, who was commander at Walter Reed from 2002 to 2004, should resign. Kiley responded, "I still think I’ve got the right skill sets and the right experience to fix these problems."
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