Public Health Emergency Preparedness

Chapter 4 (continued)

4.7 Preparing to Staff a Surge Facility

We identified possible staffing sources based on Federal, State, and local resources. Declaration of a local, State, or Federal disaster activates various level emergency operations making available an array of resources.

In the event of a disaster, local governments use their own response and community-to-community mutual aid agreements first. If the disaster depletes or threatens to deplete local response capabilities, the local government requests assistance from the State.  If warranted, the State may request assistance from the Federal government and nearby States. In Massachusetts, emergencies or disasters are divided into four levels based upon the severity of the situation, the potential to intensify in severity, and anticipated local, State and Federal assistance required. Level 1 designates normal day-to-day operations while Level IV refers to an emergency event involving all State and Federal resources.⁴⁷

4.7.1 Federal Resources

National Disaster Management Teams

The primary medical disaster response personnel resource on the Federal level is the National Disaster Medical System (NDMS). Established in the early 1980's, the NDMS is a partnership between the Department of Health and Human Services, the Department of Veterans Affairs (VA), the Department of Defense (DoD) and the Federal Emergency Management Administration (FEMA), now under the Department of Homeland Security (DHS). There are approximately 7,000 volunteer health professionals organized in general and specialty teams. The general DMATs are 35-member teams, which include 2 physicians, 10 nurses, 10 EMTs/paramedics and support personnel (communications, logistics, maintenance and security) and are categorized according to their ability to respond. Each team generally has many more than 35 members to provide "redundancy for each job role." Teams are locally sponsored and community-based and maintain a Memorandum of Understanding with the U.S. Public Health Service, which enables them to be "federalized" upon activation of a team. Federalization allows team members to legally function in any State and covers liability and workers compensation issues.  Specialty teams include pediatric, burn, mortuary service, nursing, veterinarian, mental health, and pharmacy teams.

Table 10 shows team types, composition, deployment schedules, and availability of teams applicable to this project.

Public Health Service Commissioned Corps

The Public Health Service (PHS) Commissioned Corps, led by the U.S. Surgeon General, consists of approximately 6,000 officers available to "furnish health expertise in time of war or other national or international emergencies" as well as carry out other health promotional activities. Dentists, engineers, health services professionals (social workers, physician assistants, optometrists, statisticians, computer scientists, dental hygienists, medical records administrators, and others), nurses, pharmacists, physicians, scientists, therapists (physical, occupational, speech, and audiology), and veterinarians are represented in the Corps. Health professionals are assigned to Federal, State or local agencies or international organizations to accomplish their mission. There are slightly over 2,000 regular corps on active duty and about 3,900 reserve corps on active duty. There are also inactive reserve corps that may be activated with or without their consent depending on the level of emergency. In a national emergency or war, the PHS commissioned corps may be declared a military service and branch of the land and naval forces. Reserve corps officers may be called to active duty without their consent.⁴⁸

Table 11 shows approximate numbers of each type of PHS type.

The Department of Veterans Affairs

Although many clinicians are employed by VA (physicians, RN/LPNs, respiratory therapists, dentists, dietitians, medical records administrators and technicians, physical and occupational therapists, psychologists, and social workers), these staff members are permanently assigned to a facility and would not be relocated in the event of an emergency. According to a VA contact, these staff members could volunteer to assist in an emergency but, unlike the military branches of service (e.g., public health service), would not be reassigned. Their licenses, however, are recognized in any State, and any who did volunteer would not have to be re-licensed in the disaster State.

Medical Reserve Corps

The Medical Reserve Corps (MRC) is composed of community-based organizations within the Citizen's Corps and the USA Freedom Corps. Leadership responsibility of the MRC falls under Office of the Surgeon General within the Department of Health and Human Services. MRCs are locally developed and managed with local volunteers for local needs. They consist of both health professionals and interested citizens with the goal to provide an organized response during times of emergency and general public health needs. The MRC was initiated in 2002 with a $2 million grant that was extended and expanded in 2003 to $8 million. A total of 207 programs in 44 States were funded. As of September 2004, there were 212 MRC units with more than 27,500 volunteers. Grantees received up to $50,000 to begin or continue development of MRC units. MRC unit members cannot be federalized like other Federal response teams, thus are intended for use only in the local community in which they were developed. Because of their local base, MRCs will be described in greater detail under Local Resources.

Recommendation: Federal staff resources (e.g., NDMS, Public Health Service, VHA) could be made available in certain local mass casualty emergencies not designated as national.

National Urban Search and Rescue Response System

The National Urban Search and Rescue (US&R) Response System, established under the authority of FEMA in 1989 is a framework for structuring local emergency services personnel into integrated disaster response task forces.⁴⁹ There are 28 task forces (or teams) in the United States able to respond within 6 hours in the event of a disaster.⁵⁰ Teams have all the necessary tools, equipment, and personnel needed to assist in search and rescue operations. Each task force consists of two 35-person teams, four canines and a comprehensive equipment cache. Team members specialize in search, rescue, technical, medical, hazmat, or planning areas. Each team is composed of the personnel shown in Table 12.

When a Federal disaster is declared, FEMA deploys the three closest teams. Each team member is registered as a volunteer with FEMA and upon activation becomes a Federal employee with tort liability, workers compensation, and long-term liability protection. Team members may be deployed for up to 14 days. To maintain a constant state of readiness, team members attend regular drills and meetings and provide the necessary information to keep personnel files current (current physical exam, immunizations, credentials, and a criminal background check).

The Massachusetts Task Force 1 (MA-TF1) manager was contacted in connection with this study. MA-TF1 draws its volunteers from all the New England States with each position tripled filled. There are 165 people who train on a monthly basis. MA-TF1 can supply 80 people with a 4-hour notice. According to the manager's volunteer roster, the group consists of:

• Physicians (4, plus 2 veterinarians who are cross-trained as logistics people because the system does not call for veterinarians).
• Medical specialists (RNs and paramedics) (9).
• Rescue specialists, officers and managers (54).
• Canine search specialists (13).
• Communication specialists (e.g., radio technicians) (4).
• Hazmat technicians (20).
• Logistics managers and specialists (27).
• Planning managers (2).
• Rigging specialists (6).
• Safety (3).
• Search manager and specialists (6).
• Computer operators (6).
• Structural engineers (5).

Many of the volunteers, however, are cross-trained to one or more positions. The Task Force manager believed that his teams would be able to assist in staffing a surge facility. Although not all positions would be needed because they train regularly as a team, he felt that they would be much more efficient than a group of volunteers brought together for the first time in an unfamiliar stressful situation.

4.7.2 State Personnel Resources

State and County Departments of Public Health

In the event of a mass casualty event, State and county health department employees will likely be engaged in emergency management operations and not available to assist in staffing a surge facility. Under the Massachusetts Comprehensive Emergency Management Plan, the Massachusetts Department of Public Health (DPH) is the primary support agency for Emergency Support Function (ESF) 8 (Health and Welfare). If the emergency plan is activated, DPH is responsible for coordinating public health, mental health, medical, and health-care resources. They would be assisting local and regional entities in identifying and meeting the health, medical, and mental health needs of victims, emergency responders, and the general public. Since the number of physicians and nurses within the MDPH is limited, and they have other responsibilities, MDPH would probably not be a good source for staffing. (Note that Massachusetts does not have county health departments, relying instead on local Boards of Health.  In other States, staff from county departments may be able to contribute to this effort.)

4.7.3 Local Government Personnel Resources

Local city and town departments of public health, even smaller in size than State departments, will likely be involved in emergency operations and not a reasonable source for staffing a surge facility. The local health department, however, may have access to names and contact information of residents with medical credentials who may be available to assist in some capacity.  In the course of this project, one researcher was contacted by her town's public health nurse for confirmation of her nursing license and a response to whether she would be available in the event of an emergency.

4.7.4 Non-Government Personnel Resources

American Red Cross

In addition to sheltering and blood related activities in disaster situations, the American Red Cross (ARC) also provides Family Assistance Centers. These centers, staffed by mental health professionals, provide information, counseling, and support to family members affected by the disaster. A contact at ARC explained that its nurses do not typically provide direct care and would not be available to staff a surge hospital. The trained mental health workers, however, could be available provided there was a pre-established partnership with the hospital.  The mental health workers are generally licensed social workers trained by ARC. There are approximately 130 trained mental health volunteers in Massachusetts. Some are employed by the State's Department of Mental Health, which because of the State's disaster leave law would be available for up to 3 weeks to respond to a disaster. Some would be available to travel, while others could respond only locally.

Out of Area Hospitals

In the event that the mass casualty event is not widespread, it is possible that staff from out-of-area hospitals could be available. Communities would have to execute mutual aid agreements with surrounding area hospitals to specify where additional staff might be obtained.

Temporary Medical Staffing Agencies

Temporary staffing agencies provide nurses (RNs and LPNs), nurse aides, home health aides, homemakers, and allied health staff (physical therapists, occupational therapists, and speech therapists) to hospitals, nursing homes, clinics, and private homes. Agencies may be locally owned or operated or may be part of a national multi-agency corporation. Individuals that work for a temporary agency may or may not be employed in another medical setting, limiting their availability. The number of staff available to staff a surge facility would require an assessment of locally available services and the availability of out-of-area staff through a multi-agency chain. Such an assessment would be best performed by the State or local emergency management system, as agencies consider the numbers and types of clients and employees as sensitive information. Assessments would require periodic updating as agencies and individuals working through them change frequently.

Volunteer Programs

Each State (except for South Dakota) has a State agency to coordinate and oversee community service and volunteerism. In Massachusetts, the Massachusetts Service Alliance is a private nonprofit organization tasked with "creating and supporting high quality service and volunteer opportunities for all age groups." The Alliance invests public and private funds in community-based organizations. The agency's Web site (http://www.mass-service.org/) provides a complete listing and description of funded volunteer programs. These volunteer programs may provide additional sources for surge facility nonclinical staff types, which are described below.

Corporation of National Community Service and USA Freedom Corp. The Corporation for National and Community Service, created in 1994, is now part of the USA Freedom Corps, the White House initiative to coordinate citizen volunteer efforts. Senior Corps and AmeriCorps National Civilian Community Corps (NCCC), State and National programs that are Corporation programs, are potential sources for volunteer staffing for a surge facility. Each State has a Corporation office that could provide information specific to the programs and volunteers available locally.

Citizen Corps. Citizen Corps is a component of USA Freedom Corps, coordinated and managed at the local level by Citizen Corps Councils, and includes Neighborhood Watch programs, Community Emergency Response Teams (CERT), Volunteers in Police Service, and Medical Reserve Corps (MRC). CERT programs that provide training in emergency preparedness and basic response techniques and MRC programs that coordinate volunteers trained in health care and others interested in public health issues are two programs that potentially could supply volunteers to a surge facility.

Community Emergency Response Teams. In Massachusetts, there are approximately 107 cities or towns at various stages of organizing CERT teams. CERT training includes 20 hours of sessions on disaster preparedness, fire suppression, basic disaster medical services, light search and rescue, team organization, and protection against terrorist threats.

Medical Reserve Corps. There are 11 MRC teams in Massachusetts. Locally-based MRCs are partnered with local government or nongovernment organizations to coordinate the skills of physicians, nurses, health professionals, and others who are willing to volunteer during an emergency and other times of community need. Partnering entities include health departments, cities, counties and towns, churches, educational institutions, hospitals, fire departments, emergency medical service providers, nursing associations, Red Cross chapters, and DMATs.

As one MRC coordinator explained, each MRC is different, depending on its stage of development, leadership, and resources in the local community. For example, MA TF1 US&R is an MRC in addition to a FEMA search and rescue team. When formed, this MRC had a ready supply of more than 160 trained volunteers who now drill together monthly, and a paid office support staff to keep personnel records up-to-date. Another MRC, sponsored by a faith-based organization, has more than 50 volunteers, one-third of whom are medical personnel and two-thirds of whom have no clinical skills. This group consists of the following volunteers:

10 physicians 1 physician's assistant 1 public health worker 5 behavioral health/social workers 1 nurse aide 38 administrative assistants 2 funeral directors 3 financial experts 1 medical supply person

19 nurses (18 RNs and 1 LPN) 1 veterinarian 2 pharmacists 1 physical therapist 3 business managers 1 driver 2 chaplains 1 public relations expert 1 public health advisor

The coordinator cautioned that many of the clinical volunteers are employed at hospitals that would likely call them into work in the event of a disaster and thus severely limit their availability. MRCs based at hospitals would be affected to an even greater degree.

SeniorCorps. SeniorCorps recruits Americans 55 years and older to participate in a variety of programs, one of which is the Special Volunteer Program in Homeland Security, which engages people in projects related to pubic safety, homeland security, and disaster preparedness and relief. Grants totaling $8.7 million were announced in September 2004 to support more than 32,000 volunteers working on projects sponsored by 29 national and local organizations. Grant programs are underway in 23 States, with the possibility that volunteers in the surge area could be available to assist in nonclinical roles. In Massachusetts, there are 15 Retired Senior Volunteer Programs (RSVP) of which four indicate disaster preparedness activities.

AmeriCorps. AmeriCorps includes State, National and NCCC programs. AmeriCorps State programs operate within a single State, while National programs operate in multiple States. In Massachusetts, 20 State programs and 8 National programs are operating. Programs that involve full-time volunteers were considered to be a better potential source for volunteers, as these people could be moved from their current project to one related to the disaster. One of the residential programs mentioned as an example was an environmental/first responder program. Twenty-four people were currently manning a shelter opened because of a winter blizzard. Another potential source for clinical staff was from a project involving 10 half-time LPNs and nurse practitioners operating a community clinic. The AmeriCorps representative remarked that a city or town could apply for funding for a disaster preparedness program. Funding could be requested for some number of volunteers for a determined number of hours. Full-time programs consist of 1,700 hours, half-time 900 hours, and quarter time 450 hours, over the course of a year. If there was no disaster, the group could be involved in planning and preparedness activities in the community.

AmeriCorps NCCC is a 10-month full-time, team-based residential program for individuals ages 18-24 focused on disaster relief and homeland security. There are currently 1,800 volunteers organized in regional teams of 10-to-15 members with a designated leader. Participants receive a $4,000 annual living allowance and an educational award of $4,725 upon successful completion of their service. Priority is given to projects that focus on public safety, public health, and disaster relief. NCCC appears particularly well suited to assist in a surge situation as members are organized in teams, trained in CPR, first aid, and mass care and can be deployed immediately to support disaster relief efforts in cooperation with the American Red Cross and FEMA. NCCC members receive 1 month of training and then spend 9 months engaged in regional projects.

In FY 2004, NCCC engaged 1,187 members on 591 projects in 50 States. Members served with 16,000 volunteers, or about 15 volunteers per member.⁵¹ Six percent of projects focused on homeland security and 5 percent on disaster relief. Regionally, 16 percent of projects were conducted in the Northeast. According to the annual report, the team-based program model allows high volume rapid response that is extremely cost effective. In FY 2004, 545 NCCC members were deployed at the request of FEMA and the American Red Cross to assist citizens in areas hit by hurricanes.

A contact in the Northeast regional office suggested that it would be very feasible for NCCC volunteers to assist in a surge facility. Depending on the extent of the disaster, one or more of their 14 teams could be in route to the surge facility within 1 hour to assist with nonclinical tasks. Deployment of teams, however, would likely occur at the national level, with the director of operations determining which teams would be sent, as regional teams have staggered start dates. On September 11, 2001, all 16 teams at the time were deployed to New York City to assist with feeding volunteers and stacking goods and equipment in a warehouse.

4.7.5 Alternate Sources

In the event that the previous listed sources of personnel do not provide enough skilled nursing staff to support the surge hospital, we investigated the feasibility of delegating specific tasks to medical students, nursing students, respiratory therapy students and graduates, patient care assistant students, pharmacy technician students, phlebotomy technician students, surgical technology assistant students, medical assistant students, medical radiography students, faculty members, veterinarians, and dentists. Boston has a large number of medical training programs with three medical schools and several nursing schools.⁵² In cities where there are no training programs, a surge facility would not have these students and instructors available to supplement staffing.

Medical Students

According to a dean at a local university school of medicine, medical students have the requisite knowledge to work as nurses at the time they enter their third year of training but would not have had the necessary experience at that point. By the beginning of their fourth year of studies, medical students have the experience to fully function as nurses; however they would be unfamiliar with nursing protocols and the organizational structure of nursing care, so they would require some orientation and supervision. Then, the dean believes, the medical students would be capable of functioning in a fully independent mode and would possess all the nursing skills listed in Appendix C. 

Three medical schools are located in Boston. If fourth year students could be useful to perform nursing skills, there would be more than 400 students each school year located in the city of Boston. Go to Table 13 for examples of Number of Fourth Year Students per Year at Medical Schools in Boston.

Nursing Students

According to a dean of nurse education and health professions at a local community college and a professor of a 4-year baccalaureate program, nursing students would be appropriate to work at a surge facility. Nursing students gain experience performing many nursing skills during their 2-year or 4-year program; these skills and the semester at which the nursing student has the requisite experience are indicated in Appendix C. The professor of a 4-year baccalaureate program stated that the identified skills would be able to be performed by senior students who have completed a 7-week Critical Care Rotation and junior students who have completed 15 weeks of medical-surgical nursing. In addition, a student's skill level will vary depending on the curriculum content and practicum experience the student receives. Hospital policies and practice standards would prohibit nursing students from administering medications in the absence of a nursing instructor. Additionally, IV drugs or ET drugs affecting the cardiovascular system may not be administered or titrated by students, but students may monitor the effects of these drugs. Nursing students have student IDs and schools maintain a database of the student information. Although this information is confidential, in an emergency it may be possible to confirm the identity of these students. Nursing students have medical malpractice and liability insurance.

Nursing instructors also would be appropriate to work in the surge facility. Boston, has a large supply of nursing students and instructors. Go to Table 14 for examples of Number of Nursing Students and Instructors at Boston Area Nursing Programs.

Patient Care Assistants, Pharmacy Technicians, Phlebotomy Technicians, Surgical Technology Assistants, Medical Assistants, and Medical Radiography Students and Graduates

According to a dean of nurse education and health professions at a local community college, students of patient care assistant, pharmacy technician, phlebotomy technician, surgical technology, and medical assistant programs would only be appropriate for performing supportive tasks such as transferring patients and changing bed sheets. Although many of these students will have experience working in hospitals from previous jobs, they do not gain any hospital experience through their respective programs. These students may be more useful than a non-health-professional volunteer in performing these tasks, but they do not gain the hands-on experience during their studies to perform any of the nursing skills. In addition to performing supportive tasks, medical radiography students may be able to take a patient's vital signs. Pharmacy technicians assist pharmacists, which typically consists of preparing prescribed medications for patients. Although two-thirds of pharmacy technicians work in retail pharmacies, those that work in hospitals, nursing homes, and assisted-living facilities may have experience useful in a surge hospital. According to the Department of Labor Occupational Outlook Handbook, pharmacy technicians "read patient charts and prepare and deliver the medicine to patients."  They may also "assemble a 24-hour supply of medicine for each patient."⁵⁰

Phlebotomists may collect blood samples.⁵⁴  According to a dean of health professions, surgical technologists would probably not be appropriate to work in a surge facility because they do not have experience outside of surgery.  Medical assistants typically perform administrative and clinical tasks in health practitioner offices. They could perform some basic tasks in a surge facility because their clinical duties, depending on their experience and State laws, may "include taking medical histories and recording vital signs, explaining treatment procedures to patients, preparing patients for examination, and assisting the physician during the examination. Medical assistants collect and prepare laboratory specimens or perform basic laboratory tests on the premises, dispose of contaminated supplies, and sterilize medical instruments. They instruct patients about medications and special diets, prepare and administer medications as directed by a physician, authorize drug refills as directed, telephone prescriptions to a pharmacy, draw blood, prepare patients for x rays, take electrocardiograms, remove sutures, and change dressings. Medical assistants also may arrange examining-room instruments and equipment, purchase and maintain supplies and equipment, and keep waiting and examining rooms neat and clean."⁵⁵

Respiratory Therapy Students and Graduates

Respiratory therapists evaluate, treat, and care for patients with breathing or other cardiopulmonary disorders. Respiratory therapists practice under physician direction and assume primary responsibility for all respiratory care therapeutic treatments and diagnostic procedures.⁵⁶ A contact at an area hospital's respiratory therapy department stated a surge facility would have a difficult time finding respiratory therapists due to the current shortage. Respiratory therapy students would be beneficial to use in the event of an emergency and would be able to perform several of the nursing skills listed in the skills list in Appendix C. Students are able to perform many of the skills after their first semester and first year. Typical programs are 2 years. Three local schools offer respiratory therapy programs.

Dentists

In the process of diagnosing, preventing, and treating problems with teeth or mouth tissue, dentists administer anesthetics and write prescriptions for antibiotics and other medications. Dental school studies usually include anatomy, microbiology, biochemistry, physiology, and clinical sciences. Dentists might be able to supplement staff at a surge facility. The nursing skills that could perhaps be delegated to a dentist are indicated in Appendix C. Specialized dentists, such as oral surgeons, would have a more medically oriented skill level.

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