Hospitals’ Challenge: Money, Staff, Training for Next Crisis

When two bombs detonated at the Boston Marathon in 2013, Massachusetts General Hospital had nine minutes to get ready. Nursing supervisors cleared lower-priority patients from the emergency room. Environmental Services staff brought stretchers to await the surge. Doctors scrubbed up.

Staff members had trained for such emergencies so there was no guessing when the first of nearly 40 victims was wheeled through the door—even though the hospital already had almost twice as many patients as available beds.

“Everybody was able to do that without directly being told to do so because we practiced it,” said Paul Biddinger, chief of the division of emergency preparedness at MGH.

The Covid-19 pandemic didn’t test one hospital, city, or state at a time—it simultaneously tested the entire US health-care system. It froze supply chains. It sidelined sick workers and triggered early retirements. With nurses wearing trash bags because they lacked personal protective equipment and ambulances backing up outside ERs, the pandemic exposed how ill-equipped and disconnected the nation’s medical centers were for such a massive crisis.

Emergency preparedness experts say many of the more than 1 million US deaths could have been avoided if hospitals had better planned how to communicate with one another and share resources like ventilators, beds, and staff.

Despite near-universal agreement that the US should never again be so unprepared, there’s growing concern the sense of urgency is waning and the country hasn’t taken the steps to shore up its frontline medical response.

A bipartisan bill that would authorize a White House office for pandemic preparedness, coordinate public health data, and replenish the national stockpile of equipment is losing steam in Congress as Republicans resist spending more on pandemic response and Democrats prioritize abortion and gun violence. The president’s 2023 budget request hasn’t meaningfully increased the small pool of money available for hospitals to bolster staff and training.

There’s also little incentive or enforcement for them to do better: In the 18 months before the pandemic, regulators had reviewed the readiness of 2,700 hospitals nationwide. Only 5 percent were cited for being unprepared; none lost federal funding.

“I worry that we are going to very quickly forget the lessons learned during the pandemic,” said Megan Ranney, an emergency physician and dean at the Brown University School of Public Health.

‘Space, Staff, System, Stuff’

Preparedness looks different at every hospital, depending on its location and community, said Nancy Foster, vice president for quality and patient safety for the American Hospital Association. A health-care facility in California likely has a rigorous wildfire response plan, while a hospital in Florida is probably well-equipped for a hurricane.

Typically, hospitals need to consider four metrics when preparing for a surge, said David Marcozzi, a disaster response specialist at the Department of Health and Human Services during 9/11 who now works as chief clinical officer at the University of Maryland Medical Center. His shorthand description: “Space, staff, system, and stuff.”

Administrators need to weigh how to maximize the space both inside their facilities and on the grounds surrounding it. They must have contingencies to maintain proper staffing levels, and strong relationships with other institutions in their communities and states. And they need the proper equipment.

During Covid-19, football stadiums became hospitals and cafeterias were transformed into treatment sites. Health-care facilities enlisted travel nurses and the National Guard. States shipped one another ventilators and coordinated with the Strategic National Stockpile to ease PPE shortages.

But the care and response was still uneven; in many places, plans were crafted on the fly. Health-care workers got sick, or died, because they lacked the proper equipment. Patients lost their lives, families suffered.

The outcome could have been different, Ranney said, if health-care systems had planned for some worst-case scenarios, “whether it was the cost of masks and gowns going up by 250-fold, whether it was the cost of nursing staff increasing by 10- to 20-fold, or whether it was the cost of literally not having space for patients and saving human lives.”

Practicing Disasters

In the four-hour drills for staffers at Mass General, spouses, relatives, and even Boy Scouts don makeup and flood the emergency room as would-be trauma patients. Senior doctors and nurses scramble to arrange treatment, while administrators and building grounds workers have their own assignments.

When the drill ends, victims and staff unwind in a break room with sandwiches and water, reviewing what went well and what didn’t.

“Often, there is a little emotion,” Biddinger said.

Every hospital is required to conduct such training. The number of drills varies each year—MGH conducted five in 2021— and they take months to plan to ensure they don’t disrupt patient care. But each one improves staff synergy, Biddinger said.

One attempt to nationalize efforts came after 9/11 and the anthrax attacks. The Public Health and Security and Bioterrorism Preparedness and Response Act of 2002 set aside billions to support preparedness.

But money alone doesn’t guarantee success. The emergency response to Hurricane Katrina in 2005 was “catastrophic,” said Cheryl Peterson, vice president of nursing programs for the American Nurses Association.

People didn’t listen to evacuation requests; the fire department, emergency medical services, and hospitals struggled to communicate with one another. More than 1,800 people ultimately died after the storm battered and flooded New Orleans.

“Patients died because we weren’t able to get them the care that they needed,” Peterson said.

She said Katrina response failures led to “an incremental improvement” in communication and collaboration among emergency responders. But the energy for reform wanes after each disaster.

It’s also not something every hospital can afford. Preparedness “is a cost without any immediate return on investment,” said James Lawler, executive director of international programs and innovation at the University of Nebraska Medical Center’s Global Center for Health Security.

Lack of Accountability

In 2013, the Centers for Medicare & Medicaid Services proposed a more rigorous standard for hospitals. The rule, which went into effect in 2016, requires risk assessment and emergency planning; communication plans; policies and procedures; and training and testing.

Facilities must have a written policy describing their response to natural and man-made disasters, including which staff members would fill critical roles if leaders are unavailable. Hospitals that don’t comply risk being terminated from the Medicare program, typically their largest source of revenue.

The CMS encourages facilities to take an “all hazards” approach to risk assessment, planning for many different types of disasters.

Many assessments are flawed, Biddinger said, because a hospital that’s not accustomed to being a trauma center is unlikely to prepare for a surge of gunshot victims, just like one far from a water source might not bother training for a flood.

The Joint Commission, the nonprofit that accredits thousands of US hospitals, also requires them to have an emergency response plan for disasters.

Industry leaders said the standards from both agencies still aren’t enough to ensure hospitals develop meaningful plans and training, particularly with other, more pressing priorities.

Most businesses focus on the “high-probability issues” that could threaten their survival, said Lisa Koonin, founder of Health Preparedness Partners LLC, an organization that helps businesses respond to Covid-19. “Preparedness, up until now, has really been a low-probability issue.”

Ranney put it more bluntly: “The way that health care works right now, there are never resources available to have extra,” she said. When a crisis hits, “there’s just not enough slack in the system to allow us to keep delivering the level of care that we need.”

The CMS said it surveys hospitals on their readiness plans at least once every three years. Facilities that fail to meet its requirements get a chance to correct their plans, it said. None has lost Medicare funding for noncompliance.

But some say enforcement of the rules is loose.

“There’s nobody regularly checking that hospitals are doing what they’re required to do,” said Eric Toner, senior scholar for the Johns Hopkins Bloomberg School of Public Health’s Center for Health Security.

The Joint Commission standard is also somewhat of a box-checking exercise, Toner said. Most hospitals will be able to pass the standard, he said, “whether or not they’re really prepared, whether or not they’ve really done rigorous exercise, and whether or not they’ve spent any significant amount of money on preparedness.”

The CMS, along with the Joint Commission, has pledged to review and update the guidance to incorporate the lessons learned from Covid-19, from the importance of having leaders to spearhead emergency management, to emphasizing education, training, and testing. Neither has said when or how those changes will occur.

Worth the Investment

Calls to do more come as hospitals are facing dire staffing shortages, the Centers for Disease Control and Prevention lacks the ability to collect and distribute the data public health leaders need to make responsible decisions, and states and communities still see challenges in getting critical supplies.

“Every hospital across the country right now is operating on a razor-thin margin,” said Ranney, who said hospitals shouldn’t have to shoulder the preparedness burden alone. “There really needs to be more of a systemic national plan for how to think ahead and fund combined disaster preparedness.”

At a June hearing before a House subcommittee, the HHS official tasked with coordinating a national strategy urged lawmakers to provide enough funding to avoid backsliding on any progress that’s occurred in the past two years.

“Unfortunately, without additional funding, our ability to prepare for whatever comes next is severely limited,” HHS Secretary for Preparedness & Response Dawn O’Connell said.

Still, Congress seems less inclined to act than it once did.

The bipartisan pandemic preparedness bill (S. 3799) introduced by Sens. Patty Murray (D-Wash) and Richard Burr (R-N.C.) could cost billions and hasn’t moved since it was marked up in March.

Sen. Mitt Romney (R-Utah), a key dealmaker in negotiating a previous $10 billion Covid relief package, suggested he would not step into that role again because of broken trust with the White House.

While the HHS has issued $350 million of emergency supplemental funding to help respond to Covid-19, the dedicated federal funding for hospital preparedness hasn’t changed much despite the pandemic. The Assistant Secretary for Preparedness and Response awarded $232 million in 2021 and 2022, and proposed $292 million for next fiscal year’s budget.

To get funding for the program, now in its 20th year, participants have to meet dozens of requirements, from submitting spending plans and budgets to conducting exercise and attending summits. During the current year, the funds are going to just 62 recipients, mostly regional health departments that distribute money to local health-care coalitions. “Very little goes to individual hospitals,” Toner said.

Lawler, the professor from the University of Nebraska, said if the CMS changed the reimbursement formula to reward hospitals based on their level of preparedness—as it does for other priorities— “we would see a dramatic shift in preparedness in the US health system overnight.”

Meanwhile, new emergencies don’t stop: Peterson said she’s already telling nurses to prepare for an influx of monkeypox patients. Despite a recent uptick in new Covid cases, many are eager to put the pandemic behind them.

Said Peterson: “Shame on us if we forget.”