Shock to the system

Katrina highlights holes in emergency health care system

Shortly after Hurricane Katrina hit, a patient in Mississippi showed medical workers a rash that had spread across his legs. Prompted by an alert from the Centers for Disease Control and Prevention about flood-related infections from rare bacteria, workers tapped a specialized database of dermatological images to confirm the diagnosis and found the appropriate treatment for the life-threatening illness.

Help in controlling outbreaks of deadly waterborne disease is just one example of health care technology at work in the aftermath of Katrina. Even before patients walked into emergency rooms, several jurisdictions' Web-based preparedness and response tools facilitated ambulance dispatch and the allocation of hospital resources already stretched to the breaking point.

In other areas, technology failed or didn't exist. For example, communication outages were widespread, and many jurisdictions lacked systems to track the thousands of victims treated and released from medical facilities, complicating efforts to reunite families.

As disastrous as it was, Katrina proved to be the ultimate drill for many of the response systems Homeland Security Department officials had planned to rely on during national emergencies.

"It was not the disaster we planned for, but it is the disaster we got," said Bruce Thomasson, hospital bioterrorism coordinator at the Arkansas Department of Health and Human Services' Division of Health.

Saving precious minutes

In the immediate aftermath of Katrina, many Gulf Coast hospitals accessed up-to-the-minute status information, including bed availability and emergency room capacity, using EMResource, a popular Web-based service.

Workers also relied on the information to direct ambulances to the nearest hospital or the facility best prepared to handle certain types of medical situations.

Still, ambulance workers often spent precious minutes phoning nurses and other hospital staff to describe the conditions of patients they'd soon wheel through the doors of the emergency room.

"After this disaster, we are looking at ways to cut out that phone call," said David Rives, executive director of the Southeast Texas Trauma Regional Advisory Council.

The need for phone calls between emergency workers and hospital personnel did more than just consume critical time that could have been better spent on patient care. It also highlighted an overreliance on the telecommunications infrastructure, which is at serious risk of failing during emergencies.

"In addition to cell phones, we are very vulnerable if our landlines go down, given the Internet capabilities we need," said Dr. William Mason, Arkansas' director of public health preparedness.

A key lesson homeland security officials can take from Katrina is that maintaining critical communications often requires a back-to-basics approach when disaster strikes.

Telecom restoration "ranks far below power restoration," said Lisa Pierce, a vice president at Forrester Research. "In fact, it's on par with restoring services at the corner deli."

When landlines and cellular towers went down during Katrina, some hospitals and other facilities turned to satellite-based technology, if that option was available. In other instances, workers used wireless messaging devices to trade information, mostly about the transportation of patients and the availability of hospital beds, officials said.

However, a centralized patient-tracking system did not exist. "Without automated systems in place, it was almost impossible to know where evacuees were," said Andy Nunemaker, chief executive officer of EMSystem, which developed EMResource. "Also, the federal government did not have a firm grasp on how many evacuees there were, and family reunification was difficult."

Analytical data that projected the migration routes and volume of evacuees was also sorely missing, Thomasson said.

"It would have helped to have the technology that showed us what the patient flow was going to be like during an event such as Katrina," he said. "We had not visualized how patients would be coming in. We just hadn't thought that the hurricane would be bringing them in by the thousands."

Tech-based helpers

Extra messaging components for ambulance routing and tools for managing the deployment of medical resources, such as EMResource, are available but not yet widely deployed. Many municipalities are now determined to add those capabilities.

"Instead of having to call the hospitals, emergency workers will be able to enter on a screen a brief patient history -- the age, sex and chief complaint of the arriving patient," Rives said. "Emergency workers will simply input that data, select a hospital and send the message out to a charge nurse."

Houston officials plan to build the messaging capabilities into the region's existing EMResource platform, he added.

Use of EMResource is high because alternatives so far have included mostly homegrown solutions that states such as Washington and South Carolina have developed. Nunemaker estimates that about one in three hospitals nationwide now uses EMResource.

Trailing far behind EMResource in terms of usage, however, is the company's EMTrack, designed to help disaster officials track victims as they pass from on-scene responders to treatment facilities to discharge. A main objective is quickly reuniting families after a mass tragedy.

"Let's say a terrorist attack is launched against the San Francisco peninsula, which is either wiped away or uninhabitable," Nunemaker said. "You've now got 1.2 million people dead or needing new places to live, many of them hurt. All over California, these patients will have to be transferred to hospitals, mental health facilities or shelters. You really want to track who has been involved in this incident and issue those victims wrist bands with bar codes or [radio frequency identification] devices."

With Katrina, that level of detail did not exist. In fact, officials scrambled just to keep up with the tide of evacuees. For example, workers in Arkansas used in-house geographic information systems to keep tabs on Katrina victims bused to the Army's Fort Chaffee.

"As the victims came into Chaffee and then were sent to various portions of the state, we used GIS to track on a daily basis how many people were in each camp shelter site," Mason said.

Such data, however, was spotty at command centers that state officials and organizations such as the Red Cross set up, said Eric Kant, director of field operations for E Team, a company that develops collaborative software for crisis management using business intelligence-based technology.

Specifically, the company's E Team product taps into the data-mining capabilities of Business Objects' Crystal Reports. It also incorporates the geospatial functionality of GIS vendor ESRI's products. "In essence, this provides a central point to put information related to a disaster and distribute that information to stakeholders," Kant said. He added that E Team does not duplicate EMResource, which handles tactical dispatch data.

Government officials are also considering companion products to EMResource, such as Emergency Services Integrators' WebEOC. Users can choose the data they want displayed, such as national weather trends, maps or status details from nearby jurisdictions.

Tools such as WebEOC and E Team provide a range of information, but they can't compete with more tactical systems. "The biggest problem I saw during Katrina was that not everyone was using the application," Kant said. "Not everyone was aware of the product or its integration points."

Collaboration that outlasts a crisis

Medical workers will naturally take advantage of tactical systems such as EMResource during a crisis. In fact, usage spikes at such times in part because the tools allow medical administrators to fulfill federal reporting requirements including those associated with DHS' National Disaster Medical System.

The government established that system several years ago to ensure that affected communities provide a consistent health care response during natural and man-made disasters.

However, the use of tactical systems -- and overall communication among hospitals and other emergency workers -- dips dramatically after a crisis, Rives said.

"Hospitals get territorial and proprietary about their information," Rives said. "Ambulance diversion can be a problem because emergency rooms are busy, and they don't want to get busier."

Given that tendency, Houston officials are pushing health care facilities to turn crisis response measures into daily habits.

However, educating users on the importance of gathering disaster trending and tracking data is far more challenging than promoting the use of tactical crisis management systems after a disaster is over.

One of the challenges is the fact that the tools are designed for teams hastily assembled during catastrophes.

"Crisis command centers are made up of liaisons from various agencies," Kant said. "For instance, in addition to health care officials, you will often see someone who represents the county's system of public works."

Establishing unity among those groups is difficult enough, but officials must also get the participants up-to-speed fast on the use of the system during the crisis.

Standards will help

Given the coordination challenges of crisis response, many officials are pushing for better integration among emergency resource and planning applications, which can vary by jurisdiction.

"What the government needs to do is establish some standardization," Nunemaker said.

In fact, increased interoperability is a high priority. A group of companies have created the Emergency Interoperability Consortium and are partnering with DHS to promote the development of a national incident interoperability architecture.

The architecture will rely on an evolving standard called the Emergency Data Exchange Language, which is based on the Extensible Markup Language's data syntax and services. The Organization for the Advancement of Structured Information Standards' Emergency Management Technical Committee is developing the standard. Participating vendors include EMSystem, E Team, COMCARE and Alert Technologies.

Katrina has driven home the value of emergency response solutions and improved communication among emergency workers, physicians and state officials.

"Katrina has definitely been forcing issues a little more," Thomasson said.

Jones is a freelance writer based in Vienna, Va.

Practice makes perfect

When disaster strikes, health care workers and emergency response teams will stick to and be most successful with the systems they use every day rather than procedures or tools trotted out only during disaster drills.

Consider Mississippi emergency rooms during Hurricane Katrina relief efforts, where physicians had to treat Vibrio vulnificus infections caused by exposure to contaminated floodwaters. Such infections more commonly occur after a person eats contaminated shellfish, and they can be fatal.

When the Centers for Disease Control and Prevention alerted local health officials that Katrina floodwaters had caused isolated outbreaks, Mississippi doctors turned to Logical Images' Visual Dx database, a collection of medical images used to help diagnose more than 500 conditions.

Mississippi health officials bought the database long before Katrina struck using bioterrorism preparedness funds from CDC and other federal sources. They incorporated the system into their routine health care environment.

In addition to providing images associated with infectious diseases and conditions possibly caused by bioterrorism, the Visual Dx database includes images and common symptoms of routine dermatological conditions.

"Our tool is not just about preparedness but about day-to-day issues, such as detecting whether certain skin afflictions indicate a drug reaction," said Dr. Art Papier, a dermatologist and founder of Logical Images.

Frequent use of any disaster response tool is the best predictor of a solution's success during crises, others agreed.

"If it's something that people [only] learn and drill on every six months, it's not going to work during a crisis," said Andy Nunemaker, chief executive officer of EMSystem, a company that develops emergency response and health care resource management software.

Local jurisdictions hit hard by natural disasters learned that lesson early. For instance, after their experience with Hurricane Allison in 2001, Houston officials learned that the increased communication and interaction among hospital staff during a crisis often drop dramatically after the situation abates.

"We are trying to keep up the habits learned during emergencies," said David Rives, executive director of the Southeast Texas Trauma Regional Advisory Council in Houston.

-- Jennifer Jones

Emergency health services

What worked:

  • Web-based systems for regional hospital resources, such as beds available, emergency room capacity and ambulance routing.
  • Satellite-based systems for coordinating communications among emergency responders and health care facilities.

What fell short:

  • Integrated patient-tracking systems, particularly for keeping tabs on individuals after they were treated at health care facilities.
  • Analytical systems that would help project the volume and location of probable patient flows.
  • A land-based telecommunications infrastructure for voice and data services.

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