All-Hazards Disaster Planning

REPORT OF COUNCIL ON PUBLIC HEALTH

CPH Report 1-A-06
Subject: All-Hazards Disaster Planning
Presented by: William S. "Chip" Riggins, Jr., MD, MPH
Referred to: Reference Committee on Public Health

The response to the September 2005 hurricanes and storms indicated that while the emergency management plans were fairly effective, there are problem areas that need to be addressed prior to other natural or man-made disasters in Texas. The importance of preparedness is particularly acute due to looming threats of pandemic influenza, spread of avian influenza to this country, as well as bioterrorism threats. This document outlines the systems currently in place, the lessons learned from recent disasters, and recommendations for improvements in disaster planning with regard to health services in Texas.

Recommendation : Approval of attached policy on All-Hazards Disaster Planning.

ALL-HAZARDS DISASTER PLANNING
MAY 2006

Introduction  |  Response Issues  |  Lessons Learned  | Summary  |  References

I. INTRODUCTION

On Aug. 29, 2005, Hurricane Katrina hit the Gulf Coast, essentially decimating New Orleans and causing unprecedented damage to several states with thousands of lives lost along with billions of dollars in property damage. Texas "stepped up to the plate" and provided refuge for hundreds of thousands of evacuees from the areas hardest hit. Since Texas was largely spared from the massive damage from Katrina, the emergency management plans that had been put in place worked well in terms of providing immediate relief efforts to the hurricane victims.

Within only a few weeks, Hurricane Rita hit the Gulf Coast on Sept. 24, 2005. This time, Texas was not spared and sustained considerable damage in the eastern part of the state. While the areas hardest hit were primarily rural, the mass exodus from the Galveston, Houston, and Beaumont areas of Texas clogged evacuation routes for days and essentially shut down the major medical centers in that area. In addition, refugees from Katrina in the Houston area had to be evacuated again further inland in Texas. This storm put additional pressure on an already strained infrastructure and lack of communications, particularly in the rural areas, resulted in confusion and delays in restoring necessary public health services.

The results of these storms indicated that while the emergency management plans were fairly effective, there are still problem areas that need to be addressed prior to any other natural or man-made disaster in Texas. The importance of preparedness is particularly acute due to looming threats of pandemic influenza, spread of avian influenza to this country, as well as bioterrorism threats. This document will outline the systems currently in place, the lessons learned from these recent disasters, and recommendations for improvements in disaster planning with regard to health services in Texas.

Planning and Preparedness

The four stages that are used in the development of general disaster response and recovery planning are the same for development of health and medical response and recovery plans. The four phases are: Mitigation, Preparedness, Response, and Recovery.

Mitigation  includes identifying potential hazards as well as any means available to lessen the potential impact of these hazards. The overall objective of hazard mitigation is to eliminate all significant hazards facing a community or to reduce the effects of unavoidable hazards. Mitigation actions not only include responses to known hazards but also an active search for ways to prevent or reduce impacts from new ones.

Preparedness assures that you are ready to deal with a disaster in your area from the onset. Do you know the resources, both personnel and materials, you have available? What about evacuation? Do you know who, where, and when to evacuate a given area? Where are the evacuees going? Are the resources available to deal with displaced persons, those who have lost their homes and all means of providing for themselves? Preparation includes training and exercises, as well as reviewing and updating existing plans to fit changing needs.

Response addresses the immediate unmet needs of the affected population and includes such things as food, water, shelter, medicine, search and rescue operations, emergency medical support, etc. Does your community have the means to determine and then answer these needs? If not, do you know from where the needed resources will be coming?

One of the top priorities following a major disaster is an assessment of damages to hospitals, EMS systems, and other aspects of the community health and medical system. Assessment of critical needs, along with assessments of health and medical resources, equipment, and personnel to meet both immediate critical needs and long-term recovery needs of the affected population are a major part of planning and response activities.

Recovery includes such things as restoration of social and economic order, restoration of utilities, debris clearance and disposal, rebuilding the physical structure of the community, and restoration of the economy as a whole. Long-term recovery may take months or years to complete.

Recent experience has shown the emphasis in disaster planning focuses primarily on response, while the other three components, mitigation , preparedness , and recovery are just as important and need to be equally considered in the planning stages.

A.  National Level

1. National Response Plan
The National Response Plan establishes a comprehensive all-hazards approach to enhance the ability of the United States to manage domestic incidents. The plan incorporates best practices and procedures from incident management disciplines-homeland security, emergency management, law enforcement, firefighting, public works, public health, responder and recovery worker health and safety, emergency medical services, and the private sector-and integrates them into a unified structure. It forms the basis of how the federal government coordinates with state, local, and tribal governments and the private sector during incidents. It establishes protocols to help:

• Save lives and protect the health and safety of the public, responders, and recovery workers;
• Ensure security of the homeland;
• Prevent an imminent incident, including acts of terrorism, from occurring;
• Protect and restore critical infrastructure and key resources;
• Conduct law enforcement investigations to resolve the incident, apprehend the perpetrators, and collect and preserve evidence for prosecution and/or attribution;
• Protect property and mitigate damages and impacts to individuals, communities, and the environment; and
• Facilitate recovery of individuals, families, businesses, governments, and the environment.

2. National Incident Management System (NIMS)
In Homeland Security Presidential Directive-5 (HSPD-5), President Bush called on the Secretary of Homeland Security to develop a national incident management system to provide a consistent nationwide approach for federal, state, tribal, and local governments to work together to prepare for, prevent, respond to, and recover from domestic incidents, regardless of cause, size, or complexity.

On March 1, 2004, after close collaboration with state and local government officials and representatives from a wide range of public safety organizations, Homeland Security issued the NIMS. It incorporates many existing best practices into a comprehensive national approach to domestic incident management, applicable at all jurisdictional levels and across all functional disciplines. NIMS represents a core set of doctrine, principles, terminology, and organizational processes to enable effective, efficient, and collaborative incident management at all levels. To provide the framework for interoperability and compatibility, NIMS is based on a balance between flexibility and standardization.

3. U.S. Department of Homeland Security

Under the authority of HSPD-5, the roles and responsibilities of the Secretary of Homeland Security fall in four broad areas. These are: Direction and Planning, Communications and Information, Training and Continuous Improvement, and Incident Management.

4. U.S. Department of Health and Human Services
The Department of Health and Human Services (DHHS) is the U.S. government's principal agency for protecting the health of all Americans. The overall goal of HHS' preparedness and response program is to ensure sustained public health and medical preparedness within our communities and our nation in defense against terrorism, infectious disease outbreaks, medical emergencies, and other public health threats.

In a public health emergency, HHS' responsibilities include:

• Monitoring, assessing, and following up on people's health;
• Ensuring the safety of workers responding to an incident;
• Ensuring that the food supply is safe;
• Providing medical, public health, and mental/behavioral health advice; and
• Establishing and maintaining a registry of people exposed to or contaminated by a given agent.

DHHS works closely with state, local, and tribal public health departments; DHS; other federal agencies; and medical partners in the private and nonprofit sectors. Under the Public Health Service Act, HHS has the authority to:

• Declare a public health emergency;
• Make and enforce regulations (including isolation and quarantine) to prevent the introduction, transmission, or spread of communicable diseases into the United States or from one state or possession into another;
• Conduct and support research and investigation into the cause, treatment, or prevention of a disease or disorder;
• Direct the deployment of officers of the Public Health Service, a division of HHS, in support of public health and medical operations;
• Provide public health and medical services and advice; and
• Provide for the licensure of biological products.

In addition to these functions, HHS is responsible for continuing actions to acquire and assess information on the incident. Staff continues to identify the nature and extent of public health and medical problems and establishes appropriate monitoring and public surveillance. Continuing responsibilities include:

• Activation of federal health/medical response teams;
• Coordination of requests for medical transportation;
• Coordination for obtaining, assembling, and delivering medical equipment and supplies to the incident area;
• Communications to coordinate federal public health and medical assistance;
• Information requests; and
• After-action reports.

5. Federal Emergency Management Agency
T he Federal Emergency Management Agency or FEMA is a government agency which is organized under the Department of Homeland Security (DHS) in the Emergency Preparedness and Response Directorate. The agency is charged with what it defines as four domains of emergency management: mitigation, preparedness, response, and recovery. Mainly, FEMA responds to any disaster that occurs in the United States that is declared a federal disaster area by the President of the United States .

FEMA coordinates the work of federal, state, and local agencies in responding to floods, hurricanes, earthquakes, and other natural disasters. FEMA provides financial assistance to individuals and governments to rebuild homes, businesses, and public facilities; trains firefighters and emergency medical professionals; and funds emergency planningthroughout the United States and its territories.

FEMA's emergency response is based around small, decentralized teams trained in such specialties as medical care, search and rescue, and communications.

  6. National Disaster Medical System (NDMS)
These teams are federalized to provide medical and allied care to disaster victims and first responders. Teams are made up of doctors, nurses, pharmacists, etc, and are typically sponsored by hospitals, public safety agencies, or private organizations.

Disaster Medical Assistance Teams (DMAT) provide medical care at disasters and are typically made up of doctors and paramedics. There are also National Nursing Response Teams (NNRT), National Pharmacy Response Teams (NPRT), and Veterinary Medical Assistance Teams (VMAT). Disaster Mortuary Operational Response Teams (DMORT) provide mortuary and forensic services. National Medical Response Teams (NMRT) are equipped to decontaminate victims of chemical and biological agents.

7. Centers for Disease Control and Prevention
As the primary public health agency in the nation, HHS will, through its Centers for Disease Control and Prevention (CDC), work closely with local and state public health officials to identify, track, and monitor outbreaks of diseases. Disease surveillance and detection systems, including the National Electronic Disease Surveillance System, provide the framework for communication of public health information throughout the nation and help public health officials detect and fight outbreaks. CDC also has provided funding and other support to develop additional epidemiological and laboratory capacity for states and territories to address infectious disease. In coordination with DHS, HHS will provide direct public health support-both staff and medical supplies-to a state, if requested by its leadership.

Prior to the events of Sept. 11, 2001, national and state public health, intelligence, and emergency management experts were already working to anticipate and prepare for potential disasters. The U.S. Congress directed the Centers for Disease Control and Prevention (CDC) to initiate a bioterrorism program in 1999. This resulted in funding in all 50 states to support response planning at the state and local levels, as well as the development of the Health Alert Network (HAN), a national program that links local health departments to one another and to critical disaster response organizations; and the National Pharmaceutical Stockpile Program, by which critical drugs and equipment are delivered to disaster sites quickly. Additional federal measures followed with the goal of building infrastructure and improving preparedness at the federal, state, and community levels.

The CDC :

• Prevents and intervenes on disease and injury;
• Detects and investigates disease outbreaks and other health problems;
• Develops strategies for dealing with the public health aspects of an emergency; and
• Plays a role in evaluating chemical spills and environmental contamination and provides safety and health recommendations to responders (e.g., the wearing of personal protective equipment).

8. American Medical Association
The AMA is the largest single medical organization, and effectively is the center of the Federation of Medicine. It has the largest Washington, DC, presence of any medical society and has a long tradition of involvement in federal activities that affect physicians and the practice of medicine. The AMA is therefore the best candidate for a medical society that can act as a liaison to the various federal agencies involved in response planning for terrorism and other disasters. The AMA can form connections between those agencies and the appropriate state and specialty medical societies, and can more easily send representatives to planning meetings. The relationships formed also can support more routine collaborations between public health and medical practitioners for purposes such as disease outbreak prevention and control.

The AMA also can promote disaster and terrorism medical planning through the broad range of its activities. AMA representatives to the Joint Committee on Accreditation of Healthcare Organizations (JCAHO) can promote the need for hospital preparedness. AMA sections, such as the Medical School Section and the Specialty and Service Section, can provide venues for shared planning and curriculum development or adaptation by their members. Members of the Section on Medical Schools and the Resident and Fellows Section can support the inclusion of disaster medicine in their curricula. The Organized Medical Staff Section, Young Physicians Section, and House of Delegates members can be community leaders advocating physician involvement. AMA staff and elected officials already participate in a variety of federal and private sector activities that regulate or otherwise influence the practice of medicine, and can participate in disaster planning discussions as appropriate. The AMA also can draw on the expertise of specific groups within the House of Delegates that routinely consider terrorism response issues (e.g., the Section Council on Preventive Medicine and the Section Council on Federal and Military Medicine). The AMA also has existing liaisons with societies representing other health professionals who would work closely with physicians in responding to acts of terrorism or disasters, such as the American Nurses Association and the American Academy of Physician Assistants. The AMA can encourage them to educate their members and to work with physicians in developing community response plans.

9. Physician Specialty Societies
Physician membership in specialty medical societies has increased in recent years due to the fact that many physicians believe these societies better represent their specialty-specific concerns. Specialty medical societies thus are best positioned for physician education about terrorism and other disasters. Education endorsed by the specialty society is likely to have a higher impact than some other offerings, and the relevant content can be targeted for that specialty. Specialty societies also can be opinion leaders that impress on their members the importance of CME topics and materials. Specialty societies can educate their members by offering courses at specialty society meetings; publishing articles in specialty journals, including tear-out reference sheets; distributing educational materials and references prepared by topic experts and organizations; and co-sponsoring or promoting distance learning programs or other CME opportunities offered by other organizations on responses to terrorism. Because specialty societies may better understand the needs and concerns of their members, they should serve as consultants to federal planners who devise local response plans and training materials.

B.  State Level

1. Texas Comprehensive Emergency Management Plan
The State of Texas Emergency Management Plan defines specific duties of each member agency of the Emergency Management Council and provides for implementation of appropriate preparedness, mitigation, response, and recovery actions for all levels of government in Texas .

The plan establishes operational concepts and identifies tasks and responsibilities related to emergency management in the state. The plan uses an all-hazards approach to emergency management issues and is applicable in all emergency situations affecting people or property in Texas. The plan also provides for coordinated integration with federal-level contingency plans.

Under this plan, the Emergency Management Council is responsible for providing advice and assistance as needed in all matters relating to statewide emergency management activities.

This plan is set up under the Emergency Support Function (ESF) concept, with each functional group responsible for a specific emergency management activity. Each ESF has a designated Lead Agency and Support Agencies, as needed.

2. Governor's Executive Order
The laws regarding response and recovery planning are based in the Texas Disaster Act of 1975 (V.T.C.A., Government Code Title 4, Chapter 481) and the Governor's Executive Order. These are in turn based on the federal mandates in the Federal Civil Defense Act of 1950, PL 81-920, as amended; the Robert T. Stafford Disaster Relief and Emergency Assistance Act, PL 93-288, as amended; the Code of Federal Regulations, Emergency Management and Assistance, CFR 44; and Title III of the Superfund Amendments and Reauthorization Act (SARA), PL 99-499, as amended.

The Governor, as Chief Executive of the state, is responsible for directing homeland security in the state and for developing a statewide homeland security strategy. The Governor is responsible for dealing with dangers to the state and people presented by disasters and disruptions to the state and people caused by energy emergencies.

The Governor, by executive order, appointed the Director of the Governor's Office of Homeland Security as the Director of the Governor's Division of Emergency Management (GDEM) and the chair of the State Emergency Management Council (SEMC).

3. The Texas Office of Homeland Security
The Texas Office of Homeland Security is an element of the Governor's staff, which provides policy guidance for state homeland security programs and coordinates development and monitors implementation of the state homeland security strategy. The Office of Homeland Security coordinates state homeland security programs with local governments, regional organizations, and federal agencies. The Director of the Office of Homeland Security also serves as the Director of the Governor's Division of Emergency Management.

4. The Governor's Division of Emergency Management (GDEM)
The Division of Emergency Management also is an element of the Governor's Office. Chapter 418 of the Government Code assigns the division specific responsibilities for carrying out a comprehensive all-hazard emergency management program for the state and assisting cities, counties, and state agencies in implementing their own emergency management programs. GDEM, like other state agencies, also is responsible for supporting development and implementation of the Governor's Homeland Security Strategy.

Among the specific responsibilities of GDEM are:

• Emergency Planning: GDEM maintains the State of Texas Emergency Management Plan and other specialized state plans. It also adopts standards for local emergency management plans, reviews those plans, and maintains a database of planning accomplishments.
• Training: GDEM conducts an extensive emergency management-training program for local and state officials and emergency responders.
• Public Education & Information. GDEM provides threat awareness and preparedness educational materials for the public, and also provides emergency public information during disasters.
• Hazard Mitigation: GDEM administers a number of pre and post-disaster programs to eliminate or reduce the impact of known hazards.
• Response: GDEM coordinates mobilization and deployment of state resources to respond to major emergencies and disasters.
• Disaster Recovery: GDEM administers disaster recovery programs for individuals and for local governments, state agencies, schools, hospitals, and other public entities.

5. Emergency Management Council
The state Emergency Management Council, which is composed of 30 state agencies, the American Red Cross (ARC), and the Salvation Army (TSA), is established by state law to advise and assist the Governor in all matters relating to disaster mitigation, emergency preparedness, disaster response, and recovery. During major emergencies, council representatives convene at the State Operations Center (SOC) to provide advice on and assistance with response operations and coordinate the activation and deployment of state resources to respond to the emergency. Generally, state resources are deployed to assist local governments that have requested assistance because their own resources are inadequate to deal with an emergency. The council is organized by emergency support function (ESF) -- groupings of agencies that have legal responsibility, expertise, or resources needed for a specific emergency response function.

The Texas Department of State Health Services (DSHS) is the lead agency for health and medical services. During the 2005 hurricane season, DSHS partnered with TMA and the Texas Nurses Association to deploy physicians, nurses, and other allied health professionals to emergency shelters housing hurricane evacuees.

6. Critical Infrastructure Protection Council (CIPC)
The state Critical Infrastructure Protection Council, established by Chapter 421 of the Government Code, is responsible for advising the Governor on: (1) The development and coordination of a statewide critical infrastructure protection strategy; (2) The implementation of the Governor's homeland security strategy by state and local agencies and provision of specific suggestions for helping those agencies implement the strategy; and (3) Other matters related to the planning, development, coordination, and implementation of initiatives to promote the Governor's homeland security strategy.

7. The State Operations Center (SOC)
The SOC is operated by the Governor's Division of Emergency Management (GDEM) and serves as the state warning point. It uses an extensive suite of communications to receive and disseminate warning of threats to regional warning points and to state and local officials; monitors emergency situations throughout the state and provides information on these events to federal state, and local officials; and coordinates state assistance to local governments that are dealing with emergencies. The SOC coordinates 3,000 to 4,000 incidents per year. As noted above, the state Emergency Management Council is convened at the SOC to carry out state response activities for major emergencies and disasters.

The SOC and the Texas Security Analysis and Alert Center (TSAAC) are housed in a reinforced concrete bunker embedded in bedrock three stories below ground level at Texas Department of Public Safety Headquarters in north central Austin. The facility was initially constructed in 1964, at the height of the Cold War, when federal regulations required state command and control facilities to be hardened against blast and fallout from a nuclear attack. The facility was expanded from 12,000 to 22,000 square feet in 1991.

8. De partment of State Health Services Emergency Service Center (ESC)/Preparedness Coordinating Council
In Texas, the Department of State Health Services (DSHS) has implemented a number of initiatives to improve statewide response to disastrous events. Using federal grant money from CDC and the Health Resources Services Administration (HRSA), DSHS has focused on preparing the state region by region to respond to disaster. Recently, DSHS has received approval to expand the Health Alert Network to include several additional local organizations and all of the state's mental health hospitals.

A 17-member Preparedness Coordinating Council has been established to assist and advise DSHS regarding preparedness policies and procedures. This council consists of a wide variety of stakeholder organizations including representation from the Texas Medical Association.The Texas Department of State Health Services has been designated as the Lead Agency for the Health and Medical Services ESF 8 and the Radiological Protection ESF. TDH is also designated as a Support Agency to the following ESFs:

 

Communication	Hazardous Materials and Oil Spill Response
Shelter and Mass Care	Search and Rescue
Public Information	Transportation
Resource Support	Donations Management
Direction and Control	Food and Water
Human Services

                        

9. Texas Security Analysis and Alert Center (TSAAC)
TSAAC is a 24-hour centralized intelligence collection, analysis, and dissemination organization. Information is obtained from law enforcement agencies, other elements of state and local government, other organizations, and industry. TSAAC also receives reports from the public of suspicious activity possibly related to terrorism. Staffed by highly trained and experienced Department of Public Safety personnel and using sophisticated technology, TSAAC is capable to collecting, analyzing, and disseminating leads to local, state, and federal agencies to aid with the investigation of terrorism. TSAAC is collocated with the State Operations Center and there is continuous coordination between the two elements.

10.  Texas Medical Association
Most disaster responses will escalate to the state level, either because the event spreads across city and county lines or because state resources are needed to augment the local response. The broader geographic scope of the state medical society better equips it to liaise with state-level disaster planners. The state medical society should work with the state health department in these considerations and provide assistance to county medical societies. Like the local medical society, the state society should name a liaison to the state's emergency coordinator to explore medical needs during terrorism and natural disasters, and participate in disaster planning to identify ways to meet those needs. Issues may include devising model plans for the communities in that state, which the state medical society can then promulgate to guide local societies. The state medical society can educate its members on the essential aspects of terrorism and disaster medicine through CME programs at state society meetings and by articles in state society journals and newsletters. The state health department can be a resource for planning CME on this topic.

 Most laws regulating physician licensure, practice, and liability are state laws, and state medical societies should explore issues of concern in advance. Physicians will practice under unusual circumstances during a disaster, with potential needs to triage patients, use off-label or unapproved medications or vaccines, and care for victims under less than optimal circumstances. State medical societies should examine state laws governing practice and liability under these circumstances, including "Good Samaritan" laws. If necessary, the society can recommend passage of laws that will allow physicians to respond effectively during a disaster. The state medical society also can ensure that state scope-of-practice laws protect patients while allowing for emergency treatment in a disaster. In some states, nonphysicians such as emergency medical technicians can administer only medications explicitly listed by the state. If that list does not include antidotes such as atropine and pralidoxime, emergency medical technicians will be unable to provide the specific acute care needed to treat victims of severe nerve agent exposure. The state medical society can help regulators find balance when regulating scope-of-practice issues.

During the 2005 hurricane disasters, TMA developed a database of volunteer physicians and worked daily with the Department of State Health Services to identify specific needs and to deploy physicians and special services to assist with the medical needs of shelter evacuees.

11. Academic Medicine
Medical educators at all levels can participate in training physicians in the essentials of disaster and terrorism medicine relevant to their practice and specialty. Medical schools should introduce the basic elements into the undergraduate medical curriculum, including public health management of epidemics and the importance of early detection and reporting of infectious diseases. Organizations such as the Association of American Medical Colleges, the Council on Graduate Medical Education, and the Association of Academic Health Centers should be involved in this process. Residency programs should develop advanced programs appropriate for their particular specialty. Academic medical centers can also include training and education programs in disaster and terrorism medicine among their CME offerings.

It will not be necessary to create completely new curricula. The Uniformed Services University of the Health Sciences developed a curriculum that spans the four-year medical undergraduate program. While much of it is specific to military physicians in training, elements likely could be adapted for use in a shorter civilian undergraduate course. Other training resources have been or are being developed by military and public health agencies, and can be used when appropriate.

12. Texas Medical Rangers
The Texas Medical Rangers are the Medical Reserve Corp of the Texas State Guard. The Texas Medical Rangers are chartered by the Governor and will assist public health authorities in responding to contagious diseases and other threats to our public health, including bioterrorism.

In March 2003, the Texas Medical Rangers (TMR) officially became part of the Texas Military Forces (under the Texas Adjutant General) at the express direction of the Governor of Texas, and is co-sponsored by The University of Texas Health Science Center at San Antonio and other state-supported health science centers.

The goal of TMR is to respond to Texas public health emergencies including biological terrorism and natural epidemics. Its membership consists of trained, licensed, and indemnified health professionals and medical support volunteers who train and prepare to support lead public health authorities with surge and specialized emergency skills. Texas Medical Rangers serve in team response and as individual cadre who assist and train other volunteers, augmenting the emergency response efforts of public health authorities.

The TMR program expects to grow to over 1,000 volunteers statewide with units to be located in Austin, College Station, Corpus Christi, Dallas, Edinburg, El Paso, Fort Worth, Galveston, Harlingen, Houston, Laredo, Lubbock, McAllen, San Antonio, Temple, Tyler, Victoria, and Waco. In addition to these cities, the Texas Medical Rangers may establish a detachment or company in other cities or areas where 20 or more enlist and an element commander is selected and commissioned.

Benefits of joining the Texas Medical Rangers include:

• On-going medical, public health, and military training and education;
• Opportunity to advance as a commissioned or non-commissioned officer in a state military force;
• Affiliation with the Texas State Guard and the Medical Reserve Corps, which could enhance your career goals;
• Pride of a volunteer for the State of Texas, in the event of a public health emergency;
• Eligibility after one year of satisfactory service to apply for the State Tuition Assistance Program; and
• Participation in an organization comprised of conscientious and dedicated individuals - a personal growth and networking opportunity.

C. Regional Level

1. Disaster District Chairman (DDC)
Disaster Districts are the state's regional emergency management organizations that serve as the initial source of state emergency assistance for local governments. A chairman, who is the local Texas Highway Patrol commander, directs each District. Disaster District Committees, consisting of state agencies and volunteer groups that have resources within the District's area of responsibility, assist the Disaster District chair in identifying, mobilizing, and deploying personnel, equipment, supplies, and technical support to respond to requests for emergency assistance from local governments and state agencies. Disaster District chairs may activate and commit all state resources in their area of responsibility to aid requesters, except that activation of the National Guard or State Guard requires prior approval by the Governor.

If the resources of a Disaster District are inadequate to provide the type or quantity of assistance that has been requested, the request for assistance is forwarded to the State Operations Center for state-level action.

State resources committed to assist local governments normally work under the general direction of the Disaster District chair and take their specific task assignments from the local Incident Commander.

2. Councils of Government (COG)
Recommendations have been made to consolidate the District Disaster chairs (DDCs) along Council of Government (COGs) lines. It is thought that this change will streamline operations since there are fewer COGs than the current number of DDCs.

3. Regional Trauma Systems
The Omnibus Rural Health Care Rescue Act, passed in 1989, directed the Bureau of Emergency Management of the Texas Department of Health to develop and implement a statewide emergency medical service (EMS) and trauma care system, designate trauma facilities, and develop a trauma registry to monitor the system and provide statewide cost and epidemiological statistics. No funding was provided for this endeavor at that time.

Rules for implementation of the trauma system were adopted by the Texas Board of Health in January 1992. These rules divided the state into 22 regions called trauma service areas (TSAs), provided for the formation of a regional advisory council (RAC) in each region to develop and implement a regional trauma system plan, delineated the trauma facility designation process, and provided for the development of a state trauma registry.

System development activities around the state clearly demonstrate positive support for this project. A RAC has been established in all of the TSAs. Two RACs have been recognized as regional trauma systems after receiving approval of their plans. Additionally, almost 100 hospitals have been designated as trauma facilities. All of this activity has occurred despite the fact that there was no funding available for either system development or uncompensated trauma care.

4. Regional Public Health Departments
The DSHS Health Services Regions, directed by physicians with qualifications in public health and medicine, provide gap-filling public health services and serve as local health authorities in areas where there are no local health departments. By law, the regions provide basic public health and some medical services to about 25 percent of Texas' 22 million people. The regions' geographic service areas include between 16 and 49 counties and may serve up to six million people, a 2005 population that rivals states such as Alabama, Arizona, Colorado, or Indiana. Three regions include counties that border Mexico

Currently, all eight of the state's public health regions have bioterrorism response plans and smallpox vaccination and disease tracking response plans. Additionally, each of the state's Health Service Regions has an Epidemiology Response Team, consisting of an epidemiologist, public health nurse, and public health technician. The teams are available for around-the-clock-response, training and planning, assisting in developing response plans, and disease surveillance.

5. County Medical Societies
County medical society members know each other through daily interaction and often know officials in local government, emergency services, and hospitals. The local medical society is thus an important participant in community disaster planning. Each local and county medical society should appoint a staff member or member physician to coordinate the society's participation in disaster preparedness. That person should contact local government and hospital emergency coordinators to learn local emergency plans and discuss areas of need for community medical planning. These include coordinating medical care at standard and emergency care sites; organizing community-based medical resources and supply inventories; planning for receiving and integrating state and federal medical aid (including health care workers) that would be dispatched to the community; and providing public information. The medical society should participate in community disaster drills that test these plans.

The county medical society can work with the local health department to compile and maintain a contact list of physicians (both member and nonmember) in the community. In some communities, the medical society has blast fax or mass e-mail capability; in others, the local health department may be a better repository of the list, as long as appropriate safeguards for privacy are maintained. The medical society and health department should together define when it will be appropriate to contact area physicians. Plans also should identify means for contacting physicians if telephone systems are damaged or overloaded; possible alternatives include using broadcast radio and television.

The medical society also can work with the local health department to ensure that physician-friendly reporting mechanisms are in place, and that a two-way flow of information exists to provide incentives for physician collaboration. This may include mechanisms for the health department to routinely update area physicians with relevant information about immunization, local patterns of antibiotic resistance, seasonal changes in disease incidence monitored by the department, or information of immediate clinical relevance such as rapid notification of a newly recognized outbreak of foodborne illness. The health officer also has authority to declare quarantine, and physicians involved in community planning should understand the circumstances in which quarantine is appropriate. During a disaster, the health department and the medical society can each carry out complementary, previously determined roles in surveillance, health care, and public information. All of the above should be coordinated with the education, training, and planning underway in the governmental sector, especially in the local and state health departments.

The medical society can be a venue for physician education. Medical societies should include CME on the essential aspects of terrorism and disaster medicine in their educational seminars. The medical society can also work with sponsors of local CME efforts to promote this subject as a topic for hospital grand rounds and other CME programs. Individual members who are particularly interested may become peer leaders and educators.

D. Community Level

Planning, response, and recovery all begin at the local level. State response activities depend on events at the local level. Activation of the Federal Response Plan (FRP) for catastrophic disasters requires a request by state officials, when the resource needs of the local jurisdiction exceed state resource capacity. State response and recovery operations normally follow a request for assistance by local officials after a determination that local response capabilities have been overwhelmed.

1.  Local Emergency Management and Homeland Security Organizations
Mayors and county judges have responsibility for emergency preparedness and response within their jurisdictions. These officials may appoint an Emergency Management Coordinator (EMC) to manage day-to-day program activities. Local emergency management and homeland security programs include threat identification and prevention activities, emergency planning, providing or arranging training for local officials and emergency responders, planning and conducting drills and exercises, carrying out public education relating to known hazards, designing and implementing hazard mitigation programs, coordinating emergency response operations during incidents and disasters, and carrying out recovery activities in the aftermath of a disaster.

Local emergency management and homeland security organizations may be organized at the city level, at the county level, or as an interjurisdictional program that includes one or more counties and multiple cities. Local emergency management and homeland security organizations may be organized as part of the mayor or county judge's staff, as a separate office or agency, as part of the local fire department or law enforcement agency, or in other ways. Emergency management and homeland security agencies may be identified as emergency management offices or agencies, homeland security offices or agencies, or some combination of the two.

Most local governments have an Emergency Operations Center (EOC) staffed by members of its various departments that is activated to manage the response to major threats and incidents and coordinate internal and external resource support. Some local governments have an alternate or mobile EOC as well. Most local governments use the Incident Command System (ICS) as their incident management scheme. Under ICS, an Incident Commander typically directs the on-scene response by local responders from a field command post set up at or near the incident site. Responders from other jurisdictions and state and federal responders that have been called on to assist when local resources are inadequate to deal with a major emergency are integrated into the local incident command system.

2. Health Care Facilities
In any disaster, health care facilities such as hospitals will bear the brunt of acute care for affected patients. As with routine medical care, disaster care requires specific procedures and equipment. In addition, a biological terrorism event will require specific infection control measures. The health care facility must train staff accordingly and check preparedness through appropriate test exercises.  

Essential Procedures and Equipment:

• Adequate personal protective equipment for hospital staff;
• Supplies, procedures, and designated external areas for decontaminating patients prior to entry into the treatment area;
• Procedures for controlling access, patient flow, and holding areas;
• Adequate supplies of specific antidotes;
• Access to information resources; and
• Public information.

During a major disaster all area hospitals will be involved, perhaps beyond capacity. All will eventually run short of essential medications, supplies, and staff. In addition to their individual planning, all hospitals in the community should participate in area disaster plans to discuss patient allocation and distribution, resource sharing, provisions to expand bed capacity (e.g., identifying facilities to house overflow patients), and mechanisms to distribute resources that will be sent to the community in time of need.

Physicians and their staff organizations should be advocates for these measures in their health care facilities. They should be involved in planning and assessing the outcomes of training and practice drills that involve the facility, the local health department, and local emergency response units. They also should participate in hospital purchases of necessary equipment and help ensure that it is adequate for the task and conforms to appropriate recommendations issued by state and local health departments, the CDC, the Occupational Safety and Health Administration, and the Environmental Protection Agency. To ensure that hospitals meet necessary minimum standards for preparation, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and state licensure authorities should include evaluation of hospital plans for terrorism and other disasters as part of the periodic accreditation visits conducted by their representatives. (This goal is greatly facilitated by a new JCAHO standard on emergency planning, released January 2001). Hospital laboratories and emergency departments should have mechanisms to ensure prompt reporting of relevant cases to public health authorities.

3. Local Emergency Management Services
The Texas legislature wanted trauma care resources to be available to every citizen so the Omnibus Rural Health Care Rescue Act was passed in 1989. It directed the Bureau of Emergency Management of the Texas Department of Health to develop and implement a statewide emergency medical services (EMS) and trauma care system, designate trauma facilities, and develop a trauma registry to monitor the system and provide statewide cost and epidemiological statistics.

Rules for implementation of the trauma system were adopted by the Texas Board of Health in January 1992. These rules divided the state into 22 regions called trauma service areas (TSAs), provided for the formation of a regional advisory council (RAC) in each region to develop and implement a regional trauma system plan, delineated the trauma facility designation process, and provided for the development of a state trauma registry. Local EMS service representatives attend regular meetings of their RACs. RACs have become heavily engaged in the development of disaster plans for their Trauma Service Areas and they work closely with the hospitals, emergency departments, and other partners to coordinate their disaster plans.

4. Local Public Health Departments
The local health department or other appropriate agency should have a mechanism for informing physicians of essential information on a newly recognized outbreak, updated response plans, etc. This will allow physicians to more effectively recognize cases, be able to respond to questions from patients and families, and respond to community needs.

Because physician reporting to the health department will be critical to starting a community response, the health department must make reporting as easy as possible. Physicians should be able to report a case 24 hours a day, 7 days a week. The system should encourage early reporting, even on the basis of suspicion before confirmation. The reporting physician should have immediate or rapid access to a reputable authority who can provide additional guidance on confirmation and treatment of the patient. Existing or proposed confidentiality regulations should include provisions to permit such consultation. The medical leadership of the local health department must be particularly knowledgeable and skilled in the management of natural and biological disasters.

Texas local health departments/districts provide services that vary from comprehensive (providing a full array of essential public health services in the areas of environmental health, regulatory services and oversight, communicable disease, surveillance, and population assessment) to limited (providing only water and sanitation services). Texas currently has 63 "full service" local health departments that receive state funds for public health infrastructure to provide essential health services in their communities. An additional 81 local health departments are considered "limited-service" and receive no state public health infrastructure funds, but may receive state funds from a specific program area, e.g., immunization. Physicians in counties with limited or no local public health departments should contact their regional director for information and assistance.

Currently, 50 of the state's local health departments have developed bioterrorism response plans.

5. Physician-specific Issues in Community Planning

Every community should have a disaster plan that prepares for the natural and terrorist emergencies most likely for that area. This will involve coordination of diverse agencies including health departments; police, fire, and emergency medical services; utilities; government officials; hospitals; infection control specialists; schools; local military installations; large employers; and others. Physicians should ensure that the health and medical components of these plans include essentials for effective physician participation in disaster response.

The medical resources of the community must be used effectively. A list should be available with contact information (telephone numbers, fax, pagers, etc), specialty, and location for every physician who could serve. Alternate systems, such as use of broadcast media, should be considered in case of telephone system overload. At least one organization, preferably with a back-up, should have the designated lead for contacting physicians through blast fax, mass e-mail, etc. The local health department should have access to this mass communication system to rapidly disseminate information. If possible, plans should include provision for physician assignments during a disaster, such as to which hospital or other facility each physician would report.

6. Citizen Corps/Medical Reserve Corps
Some communities have chosen to develop their own Medical Reserve Corps Units and identify the duties of the MRC volunteers according to specific community needs. For example, MRC volunteers may deliver necessary public health services during a crisis, assist emergency response teams with patients, and provide care directly to those with less serious injuries and other health-related issues.

The Medical Reserve Corps (MRC) Program coordinates the skills of practicing and retired physicians, nurses and other health professionals as well as other citizens interested in health issues, who are eager to volunteer to address their community's ongoing public health needs and to help their community during large-scale emergency situations.

MRC volunteers may also serve a vital role by assisting their communities with ongoing public health needs (e.g., immunizations, screenings, health and nutrition education, and volunteering in community health centers and local hospitals). Once established, how the local MRC unit is utilized will be decided locally. The MRC unit will make decisions, with local officials, including the local Citizen Corps Council, on when the community Medical Reserve Corps is activated during a local emergency.

E. Business Level -- Individual and Group Physician Contingency Practice Planning and Preparedness

Broad, agency-based readiness is essential and so is individual preparedness. Physicians must have a strategic plan for everything from evacuating their office building to protecting employees during a communicable disease outbreak. Doctors should prepare to maintain the continuity of their practice and to provide treatment during a disaster. And finally, they should make arrangements to maintain communication with their families.

Disaster experts recommend 10 ways for physicians to ready their practice before an emergency strikes:

• Develop a disaster plan.
  Conduct a risk assessment of all potential hazards or emergencies for your practice and develop a disaster plan based on that information. Include emergency escape procedures, procedures to account for all employees and visitors, and procedures for reporting emergencies to local authorities. Practice the plan with your office staff.
• Back up critical data.
  Back up medical records or critical data frequently throughout the day. Keep copies of data at a remote site or online. Utilize Internet-based services such as  www.EZbackup.com , which can back up files from a computer every 24 hours.
• Keep a phone list.
  Keep a current phone list of all office staff members and provide a copy to key staff. If you have a voicemail system at your office, designate one remote number on which you can record messages for employees and provide the number to all employees.
• Purchase food and water.
  Buy food and water supplies that will sustain you and your office staff for three days. Choose nonperishable food items such as canned meals, fruits and vegetables, and granola or energy bars. A small water purifier is recommended as well, in case of water contamination.
• Create a disaster supplies workplace kit.
  Put together a disaster workplace kit of essential items that your practice will need in an emergency, such as a flashlight with extra batteries, a battery-powered radio, nonprescription medications, blankets, plastic garbage bags, and a manual can opener.
• Conduct communicable disease surveillance.
  Be on the alert for any diseases that are reportable to the local health department, such as West Nile virus or avian flu. If you see a patient presenting with an unusual symptom or disease, report those cases as well in order to prevent the spread of a potential communicable disease.
• Read up on biological agents.
  Review information on biological agents, such as anthrax and smallpox. Know about symptoms and treatment. Identify resources where you can get reliable and up-to-date information on biological agents, such as Web sites of local health departments and www.texmed.org .
• Stock up on basic personal protective equipment.
  In case of an epidemic or communicable disease outbreak, you should have plenty of personal protective equipment, such as masks, gloves, and goggles. Coverings like these are essential to minimize exposure. Initiate purchasing plans with supply vendors and distributors for protective equipment and other medical supplies to avoid running out.
• Have first-aid kits and wound care supplies available.
  During a disaster, patients who don't require immediate care may be triaged to your practice. These patients typically suffer from orthopedic and soft tissue injuries that are handled easily by first-aid kits and wound care supplies such as casts and splints.
• Adopt a family disaster family plan.
  The American Red Cross has an online family disaster plan that you can use to maintain communication with your family during an emergency. Discussing possible hazards and practicing your plan with your family will ensure your individual preparedness.

II. RESPONSE ISSUES

A. Incident Management Teams

An incident management team (IMT) is a group of highly-trained first responders with specialized skills to manage an incident. Regardless of the jurisdictions involved or the level of complexity, an IMT can deploy within hours to provide incident command across the full spectrum of an evacuation process. IMTs deployed by the state in the event of an emergency will provide the rapid, well-executed response needed to manage a large-scale evacuation and minimize loss of life.

The state has the capability and capacity to provide IMTs when needed anywhere in the state to assist local governments for all hazards. It may be beneficial to pre-deploy these assets and put them under the command of a Regional Unified Command or the Incident Command in specific areas. These assets include resources and capabilities from:

• State Emergency Response Team (SERT);
• State Rapid Assessment Unit (RAU);
• Texas Army National Guard Task Force (TANGTF);
• Texas Task Force One (TTF#1);
• Texas Joint Air-Ground Coordination Team (TJAGCT);
• Texas Medical Rangers.

B. Command and Control

There is a critical need to have clear-cut command and control techniques in directing the response to emergencies of all types. Confusion results when leadership authority "blurs." It is essential to strengthen leadership and staff capabilities in assuring a rapid assessment of health conditions and coordination for support managed across local, state, and federal agencies.

1. Logistics
It is critical to provide volunteers details about the type of conditions they will face upon deployment. Many volunteers are hesitant to respond due to insufficient information about the risks they will face. Also, volunteers need to know not only where they will be lodged, and where they will be working, but also detailed directions and travel information if they are expected to arrange their own travel accommodations.

2. Communications
In severe emergencies or disasters, often severe damage to land line telephone and cell phone systems are sustained. This adversely affects the ability to obtain damage assessments by agencies both inside and outside of the impacted areas and adds to the general confusion experienced. What works are satellite phone and 800 MHz radiophones. There may be a need for the state to consider frequency management during disasters and for assignment of 800 MHz frequencies to various Emergency Support Functions at the local level. The communications issue requires a thorough study on which a coordinated decision process and justification for investment can be founded.

3. Health Information Technology
The difficulty of caring for displaced individuals who have been separated from their usual sources of health care is understandable but difficult to fully appreciate unless you have cared for a patient in a shelter as they tried to accurately summarize their medical plan of care and medications after they have been traumatized. There is a dire need to call on the health information technology (HIT) industry to support the need for all Americans and health care providers to have access to summary health information during times of crisis, using a standard electronic Continuity of Care Record (CCR). Universal adoption of a standard electronic CCR will help ensure better-informed health care decisions and medical procedures in future emergencies.

The Texas Medical Association (TMA) has established a new department of health information technology (HIT). Health information technology refers to a series of computerized tools, particularly inter-operative electronic health records that improve the process of medical care by improving accuracy, completeness, accessibility, and timeliness of information relevant to the diagnosis and treatment of patients.

TMA's HIT department addresses the sparse diffusion of HIT into medical offices: despite the established benefits to patient care, only 18 percent of physicians report the routine use of electronic health records. The HIT department's primary task is to remedy this situation through educational programs and consultative services that create a clear pathway, first to acquisition and integration of HIT into medical offices and second into expanded uses as practices learn to generate and apply the clinical data these systems can produce.

The adoption of HIT brings immediate patient care benefits and directly contributes to the long-term goal of improved patient safety. Examples of immediate gain are automated prescription ordering systems that warn about drug interactions and disease management tools that improve physicians' ability to manage chronic illness and improve outcomes. As technology standards are adopted, interoperative electronic health records will evolve into comprehensive records of all patient encounters within the health care system.

Longer-term benefits are achieved as physician practices become more adept at using the systems to generate and understand their own data. Quality improvement activities in medical practices become more feasible. Practices can contribute their de-identified data to the local and regional data warehouses that are developing in Texas and elsewhere and evaluate their own data by the local norms generated by those warehouses. Once data standards are approved and security issues are resolved, medical data will be shared by health care providers though Regional Health Information Organizations and eventually national and perhaps even international organizations.

C. Manpower

Much has been written about the deleterious effect of Convergent Volunteerism where operations can be hindered by unanticipated, unknown, or uncoordinated volunteers. Aligning one's service through the county medical society, local health department, or designated public health and medical lead agency will ensure that well intended support does not overwhelm or disrupt the response.

Good planning for use of human resources can have a dramatic impact on outcomes for victims and volunteers. The more closely matched the expertise to the need, the better for all involved. However, all too often generalists find themselves with specialty challenges while specialists encounter primary care problems. This can be prevented with good planning and execution even in the response phase of disasters and should be the norm in the recovery phase. Dedication of manpower to victim (operations) or first-responder (medical support unit) roles is desirable if at all possible.  "Drill down," through the use of disease or hazard-specific appendices to "all hazards" plans is necessary to ensure that as many special needs patient categories as possible are planned for and resources aligned.

D. Shelters

Shelters, if not well run, frequently become the second disaster. Emergency rooms should not become the source of care for the chronic care needs of sheltered individuals nor should public health department staff be forced to leave their positions of ensuring community-level preventive medicine (epidemiology, outbreak investigation, communicable disease control, food and water safety) to refill medications, check blood pressures, or measure blood glucoses.

Volunteer physicians and nurses should be available to "triage" evacuees as they arrive at the shelters and have contact lists of physicians who are willing to accept these patients on a temporary basis until they are able to return home or find permanent residences.

It is important that all emergency shelters be integrated into the state Incident Command Structure (ICS) and the local Emergency Operations Center. Unofficial shelters tend not to know the procedures and command structure of emergency management causing difficulty when the state receives a request for medical and health assistance from one of these unofficial sites. Working through ICS is the proper mechanism to ensure that staffing and resources can be provided in an efficient and effective manner.

E. Special Needs Populations

Texas must do a better job of planning for the care of special needs populations (persons who are aged, have Alzheimer's, have Dementia, have a physical disability, children with special health care needs, children without caretakers, those who are hearing impaired, those who are deaf, those who are blind, those who have a mental illness, persons suffering from substance abuse, and mothers with newborns). There must be a huge effort to rapidly align physicians with competencies to handle these special populations with persons with these special needs. Physicians must be a part of the discussions and efforts to plan for the special needs population.

Special consideration should be made to plan appropriate transportation of fragile patients to areas of safety and the establishment of special shelters to accommodate their needs.

F. Pharmacy Issues

In the aftermath of an emergency or disaster, barriers related to insurance company policies that prohibit individuals from getting prescription refills out of cycle must be overcome. Additionally, TMA should work closely with DSHS and pharmaceutical companies to assist displaced physicians or those who through loss of electricity have suffered loss of expensive vaccine inventories.

Care must be taken to have adequate supplies of specialized medications for displaced individuals (e.g., HIV medications, anti-rejection drugs for transplant recipients).

G. Behavioral Health

Adequate mental health provider emergency response plans are an important and often overlooked component of alleviating post-disaster demands on physicians and hospitals to provide mental health services. Collaboration is required with government and non-governmental agencies to ensure mental health needs of special needs shelter evacuees and the general population are adequately supported. Special consideration should be given to the planning of supplies to address problems of substance abuse (e.g., methadone).

H. Quarantine

Quarantine, according to the Centers for Disease Control and Prevention (CDC), is the separation and restriction of movement or activities of people who are not ill but who are believed to have been exposed to infection. In an effort to prevent transmission of disease, people are usually limited to their homes but also might be quarantined in community-based facilities or, on a wider basis, by closing borders or erecting geographic barriers. With this in mind, it is easy to see why the approach can become entangled in serious issues of civil liberty, patients' rights and the doctor-patient relationship.

Physicians must do everything possible to protect the rights and privacy of patients without compromising public well-being. In other words, physicians need to enforce quarantine, but they should strive to see that it is well-implemented and that those affected are well cared for.

In this situation, physicians should seek to ensure that the least restrictive quarantine measures are used to minimize the negative impact on the community while still providing, to the extent possible, for individual needs. The quarantine should result from valid science and not simply target socioeconomic, racial, or ethnic groups. Physicians also should advocate for the highest possible level of confidentiality of personal health information in the context of public health reporting.

In addition, physicians are responsible for encouraging patients to follow quarantine measures by educating them about the potential harm they pose to themselves and to others. If the patient doesn't comply, physicians should support mandatory action.

Meanwhile, physicians also should be vigilant in meeting mandatory illness reporting requirements, minimizing the risk of transmitting infectious diseases to patients, staying well so they remain able to provide care to others, and seeking treatment if they think they might be ill. Frontline doctors have an increased ethical obligation to avail themselves of protective and preventive steps and to adhere to mandated public health interventions.

III. LESSONS LEARNED

A. All Hazards and Medical Preparedness

In August 2005, the Texas Institute for Health Policy Research used a survey instrument and focus group research to gather information about regional preparedness. Surveys were completed by 160 stakeholders and 221 people participated in the focus groups, representing the following types of organizations: academia, advocacy associations, clinics, councils of government, city and county governments, county judges, EMS/EMT/First Responders, hospitals, local health departments, regional advisory councils, regional health directors, state hospitals, veterinarians, and volunteer organizations. Participants were asked about their perceptions as to their community's level of preparedness for a disaster, how well the various response entities work together, and the sufficiency of resources to handle a disaster.

In general, participants agreed their communities are better prepared to prevent or prepare for all-hazards threats than they were three or four years ago, and that, at least on paper, they have response plans ready. The majority concluded, however, that they are not truly disaster-ready because of a variety of issues. Most groups also felt they were more prepared for natural disaster than for bioterrorism or chemical threats and that even if they could manage an immediate response to a disaster, they were not prepared for the aftermath and possible long-term needs of their communities. Many groups noted that physicians, local elected officials (primarily county judges), and clinics were less likely than other stakeholders to be involved in planning and preparation.

1. Communications
Cited frequently as a problem, communication issues seemed to be a significant point of frustration. The groups referred to communication problems in terms of lack of a specific system that is uniformly used (technology) and common terminology, but they were equally adamant that all of the various levels and types of emergency responders need to talk to and work with each other more regularly to build relationships and understand each others roles and capabilities better. Particularly in rural areas, there is a need for additional training about how to use communications equipment. The groups noted that their interpersonal communications and relationships are improving continually and that they are trying to coordinate better. A few groups agreed that they communicated fairly well, at least among themselves.

Participants felt that the state could take a stronger role in improving communications by providing more leadership about what equipment should be purchased, screening vendors, improving coordination of roles at the state level so that local groups do not receive inconsistent messages, and simply communicating more often and directly with each other and local communities. Additionally, they wanted to see DSHS and other agencies relating to disaster response work more closely together, particularly in terms of the requirements they impose on local communities. Another way DSHS could help communities is to help regions share best practices and "lessons learned" with each other and to clarify various roles.

2. Funding/Resources
Deemed a serious problem across the board, funding restrictions and unreasonable grant requirements actually precluded communities from applying for or using grant funds.

Respondents felt very strongly that the state should allow communities to decide how to use the money for projects based on local needs, and that blanket requirements wasted resources, either by creating redundancy, or by forcing a one-size-fits-all approach to a problem that may not work in some communities. In general, communities would like the state to provide direction about what needs to be done (statewide goal) and accountability measures, then let communities accomplish the goals as they see fit.

3. Training Issues

Every group said that training has improved considerably since 9/11 and that some of the training has been excellent. They uniformly agreed that drills and exercises that pulled in all stakeholders just as a disaster would were the most beneficial, in terms of useful lessons, as well as building stronger relationships, communicating, and understanding each other's roles.

There were several training issues that the groups identified as critical:

• Training the "higher ups" has gone fairly well, but there is a vital need to provide and require more training for the true first responders who will be first on the scene of an incident, including training about how to protect themselves.
• Everyone who will be called upon to act needs to have training, but elected officials, doctors, other health care professionals, and private clinics are difficult to involve in training and coordinating activities. It should be noted that DSHS hopes to strengthen its relationship with the Texas Medical Association and to work with the association in improving disaster response training for physicians.
• There is a need to create stronger incentives for training. Rural areas in particular mentioned how hard it is to dedicate time for limited staff to be away for training, especially as each staff member may "wear many hats." Groups suggested free training, and ensuring that it is accessible and well-publicized.
• It is difficult to know which training sessions are most beneficial. The groups suggested that training calendars and databases online should include information about what exactly each training session offers and which ones have been most useful and well taught.
• There are limitations on out-of-state travel for training for state employees. Participants felt they could benefit from different perspectives and best practices from other areas of the country.
• Ongoing training is critical for maintaining volunteers and for maximizing their usefulness. Rural areas will be dependent on them in a disaster.
• Untrained or poorly trained volunteers are less likely to do their jobs in the face of a real disaster, or they could even be an impediment.

Participants repeatedly stressed the need for integrated "hands on" training and the need to involve physicians, other private health care practitioners, and local elected officials.

4. Other Notable Concerns

• Regional Advisory Committees (trauma service regions), or RACS, were often praised for their coordination and leadership.
• One of the state's roles should be to establish benchmarks for preparedness for all communities, then to tie funding from all streams to the benchmarks so that there is consistency in requirements.
• The reorganization of the state health and human service agencies caused instability and staffing issues that need to be addressed.
• School nurses are critical for surveillance and need to be involved in coordination of response. They are the primary health contact for many families.
• There are too many jurisdictions that overlap - FBI, COGs, RACs, public health regions, etc. This has caused problems.
• Hospitals do not have adequate surge capacity for disasters, nor do they have adequate pediatric specialization in many areas of the state.
• Many rural areas have plans in place, but lack the people to staff them. Maintaining volunteers is a serious concern, as there will not be enough professionals to deal with disaster.
• Schools are not included in planning and should be. Responders will be worried about their children during a disaster.
• Public health is poorly understood. Statewide public awareness and training is critical.
• The business community needs to be involved in preparing. Many businesses have response plans and resources that responders do not know about that can be useful during a disaster. There needs to be an incentive for businesses to share resources and join in regional coordination efforts.
• Contract management at the state level needs improvement.
• Volunteer databases and registration needs to be better coordinated to address duplication.
• Ensure that required training is offered at regular intervals and that it is updated continually.
• Communities will not be able to meet the mental health needs following a disaster. Clergy, volunteers, social workers, etc. should be trained to help those who need it.

B. State Volunteer Healthcare Professionals Recruitment and Deployment

The Texas Department of State Health Services was responsible for providing the emergency support function of health and medical activities, including the recruitment, coordination, and deployment of volunteer health professionals (VHPs). Prior to the hurricanes, DSHS' formal Emergency System for Advance Registration of Healthcare Professionals (ESAR-VHP) had been in the development stages. The state's ESAR-VHP efforts have been closely coordinated with the Texas Nurses Association (TNA) and the Texas Medical Association (TMA), each of which were key partners to recruit, coordinate, and deploy VHPs under the auspices of the state. Both TNA and TMA worked through their professional memberships to assemble, deploy, and coordinate volunteer health professionals (VHPs) by utilizing their organizations' databases as resources for assembling volunteers.

At the time of Katrina's landfall, TNA's membership consisted of approximately 240,000 actively-licensed Registered Nurses (RNs) and Licensed Nurse Practitioners (LPNs). TNA had been actively recruiting nurses into its database of volunteer health professionals prior to the hurricanes. A total of 1,200 TNA members indicated they would be able to volunteer services in response to the need for VHPs.

TMA's membership consists of over 41,000 physician members. Each member of TMA is required to be an actively licensed Texas physician. TMA established the volunteer database initially in response to the Hurricane Katrina and continued its use through the response to Hurricane Rita.

In the aftermath of Hurricane Katrina, Texas received the majority of evacuees. The evacuees were placed into evacuation centers and shelters throughout Texas, with a concentration in the state's major metropolitan areas including Dallas, Houston, Fort Worth, Austin, and San Antonio. The metropolitan population centers had a concentration of medical and health assets available, including mass shelter facilities, public health resources, and local medical professionals.

In the aftermath of Hurricane Rita, DSHS set up an 800 number to take in information from people who wanted to provide either medical or nursing services, and to disseminate information to active volunteers. DSHS also established a temporary Web site to register other licensed health professionals, excluding MD/DOs and RNs, interested in volunteer health services during the response effort. Additionally, the DSHS initiated an e-mail campaign to keep the entire state's medical community abreast of the overall response effort with information on the state's strategy for utilizing VHPs, including what specialties and medical care may be needed. It was noted that the e-mails were widely distributed and forwarded throughout the medical community, facilitating a broad scope of awareness and response.

In response to Katrina, Texas officials concentrated their efforts on receiving and caring for the influx of volunteers from Louisiana. The state did not officially deploy VHPs outside of the state during Hurricane Katrina. In caring for the evacuees, most VHPs were coordinated locally and regionally, in keeping with the state's emergency response plan. By not having an integrated ESAR-VHP System, the state was unaware of the majority of personnel deployments that were coordinated locally and regionally. However, the state provided VHPs for support efforts with Katrina. Texas officials reported 53 formal requests for 234 licensed VHPs, consisting of 125 RNs, 5 LPNs, 53 MD/DOs, 5 physicians' assistants, 5 mental health workers, 10 pharmacists, and 31 technicians. DSHS worked closely with TMA, and the TNA, conducting daily conferences, and utilizing both associations to coordinate efforts with their members interested in volunteering services.

In preparing to respond to Hurricane Rita, the state's overall emergency response effort was complicated by the large number of uncertainties as Hurricane Rita approached landfall. The state had to determine how to evacuate and care for the large number of people requiring special medical attention, including the elderly from the Houston and Galveston areas. Included in the evacuee population was the large number of Hurricane Katrina victims who had been housed throughout Houston area shelters. To DSHS officials, it was apparent that local and regional capabilities would need to be supplemented to provide medical care.

The communications and coordination processes between the DSHS, TMA, TNA, and the local authorities requiring resources were more challenging, and less cohesively coordinated than what was experienced during the response to Hurricane Katrina. DSHS' role with Hurricane Rita was much more significant than it was during Hurricane Katrina because local and regional resources would not be sufficient to provide for the needs of the new victims and those displaced by Hurricane Katrina.

Over 200 ad hoc shelters were established in the wake of Hurricane Rita. The information provided was initially incomplete, and the general situation was changing rapidly in the days after the hurricane's landfall. VHPs also were confronted with incomplete information on the level of safety in areas of deployment, road conditions, and lodging. Once deployed, VHPs relied extensively on local sheriffs to assist VHPs with their finding the precise location where they were needed. The state's call center was extremely active with VHPs seeking detailed information on their deployments.

There was wide use of an ad hoc Web site established by the state, which offered "Just in Time Learning," and included an emergency contact form, details on how certain shelters are run, prime ways to screen patients, and necessary gear for each mission. The Web site received approximately 14,000 hits daily during the early Hurricane Rita response efforts.

A major challenge with the relief effort was that the efforts were concentrated in areas that were rural, difficult to establish communication with, or difficult to reach. VHPs were often responsible for arranging their own transportation. Fuel shortages were rampant throughout eastern Texas.

Additionally, many of the shelters established to provide care for victims were not established under the auspices of local or state authorities. The individuals establishing them were unfamiliar with the incident command structure, did not know how and with whom to communicate and coordinate requests, or were unable to acquire the assistance necessary. The combination of multiple unofficial shelters, in difficult to reach areas, and an inability to communicate consistently with those shelters, created challenges for Texas in terms of a response strategy.

In all, during the Hurricane Rita response Texas received formal requests for 280 VHPs, including 133 RNs, 29 LPNs, 60 nurse assistants, 6 LPNs, 27 physicians, 7 physicians' assistants, 5 mental health workers, 5 social workers, 4 pharmacists, and 4 EMTs.

For VHPs deployed under the auspices of DSHS, the VHPs received liability protections. The Governor signed an executive order providing some protections for liability exposures of the VHPs.

In addition to DSHS coordinating Texas licensed VHPs, DSHS also was responsible for managing the issues related to out-of-state VHPs seeking to provide assistance. Out-of-state nurses and physicians did arrive to help, both after Hurricane Katrina and with Hurricane Rita.

VHPs provided under federal efforts coordinated by the U.S. Department of Health and Human Services (HHS) were given appropriate Texas licenses. Texas officials would not allow out-of-state VHPs to practice without appropriate Texas licenses.

After the Hurricane Rita relief efforts, numerous VHPs had concerns and issues they expressed to DSHS. It was indicated that the VHPs were fearful of being put in a position that they would have to perform services that may have jeopardized their own licensure. For example, nurses reported having to substitute medication or offer no medication to patients in need due to a lack of proper medications. These types of issues typically resulted when nurses tried to treat patients at unofficial shelters.

  Significant Lessons Learned

§ It is critical to provide volunteers with details about the type of conditions they will face upon deployment. Many volunteers were hesitant to respond feeling that they had insufficient information about the risks they would be facing. Also, volunteers need to know not only where they will be lodged, and where they will be working, but also detailed directions and travel information if they are expected to arrange their own travel accommodations.

§ It is important that all emergency shelters be integrated into the state Incident Command Structure (ICS) and the local Emergency Operations Center. Unofficial shelters tend not to know the procedures and command structure of emergency management, causing difficulty when the state receives a request for medical and health assistance from one of these unofficial sites. Working through ICS is the proper mechanism to ensure that staffing and resources can be provided in an efficient and effective manner.

§ It is helpful for state medical societies to work with the state on preparedness planning and preparedness programs. Having some established relationships significantly helped coordinate efforts and provided for consistent public communications to VHPs.

§ It is important to decide how the state will reimburse or pay for certain costs associated with a deployment for VHPs, including transportation, lodging, and food for VHPs. This information should be made available to VHPs.

§ It is essential that scope of care issues and the latitude health professionals have in administering services during a disaster, without compromising professional licensure, be examined nationally, and for these issues to be better communicated to volunteers during a disaster relief effort.    

Recommendation for HRSA ESAR-VHP Program Improvement

§ The ESAR-VHP Guidelines should provide information and standard instructions on how resources are requested from the various authorities, and places of care, which may require VHPs in an emergency.

§  There is a need to address spontaneous volunteers in the ESAR-VHP Guidelines. Texas officials found that people were simply showing up to help, and the state could not clear out-of-state physicians to volunteer. There is a need for more efficient coordination for out-of-state licensure issues as well as a need for a system to address how spontaneous volunteers are appropriately managed.

§ There needs to be better coordination and consolidation of federal and state actions when dealing with disaster response efforts requiring the use of ESAR-VHP Systems. For example, federal authorities should be notified when an ESAR-VHP System is in use by the state so federal authorities do not seek to recruit or deploy a state's population of VHPs.

V. SUMMARY/CONCLUSIONS

When Hurricane Katrina slammed into Louisiana and Mississippi, TMA served as "information central" for the Texas medical community. That role was reprised three weeks later when Hurricane Rita closed in on Texas' state borders.

Coordination of Volunteers
In early September, medical need was heightened when severe flooding overtook New Orleans and 375,000 Louisianans were evacuated into Texas cities. Gov. Rick Perry placed an emergency call for physician volunteers. The Texas Medical Association sprang into action, calling for physician volunteers and sharing stories of heroism. In close contact with its large county medical societies, TMA helped to arrange for medical care in shelters and convention centers throughout Texas.

When Rita struck Texas' shores, TMA's list of physician volunteers exceeded 1,100. It became apparent that TMA filled an essential role for state and federal agencies by linking them with physicians willing to volunteer their skills and expertise to treat victims of the hurricane. This special resource was not available to state emergency agencies otherwise.

Financial Assistance for Louisiana and Mississippi Physicians
The scale of disaster prompted the TMA Board of Trustees to initiate the TMA Family of Medicine Disaster Relief Campaign, an effort to raise funds through TMA Foundation to help affected Louisiana and Mississippi physicians rebuild their practices and get back to caring for patients as soon as possible. TMA and TMAF each contributed $10,000 to create a $20,000 match to stimulate giving to this effort, which was launched Sept. 16. The foundation raised more than $21,000 as of Oct. 24. This total activated the full TMA/TMAF match, resulting in at least $41,000 for the campaign.

Financial Assistance for Texas Physicians
In the aftermath of Hurricane Rita, TMA received contributions of $25,000 from the American Medical Association and $200,000 from the Physicians' Foundation for Health Systems Excellence to help Texas physicians return to caring for their patients as quickly as possible. The TMA board appointed a work group to develop specific protocols for receiving and granting funds so that affected physicians could restore their medical practices and reestablish the delivery of medical care to areas of Texas affected by disaster.

Sharing the Information
Also in September, during TMA Summit 2005, the Council on Public Health hosted a well-attended two-hour open forum on Hurricane Katrina. "Tackling Disaster: Medicine's Trusted Response to Katrina," outlined TMA's response to the devastation of Hurricane Katrina. Moderated by Andrew Eisenberg, MD, Council on Public Health, the forum's featured speakers included TMA President Robert T. Gunby Jr., MD, and Board of Trustee's Chair William W. Hinchey, MD, as well as Col. William "Chip" Riggins, MD, MPH-U.S. Air Force, Texas National Guard and Chair, Council on Public Health and other leaders in the state. Michael Ellis, MD, a displaced ENT from New Orleans, described his perspective as both an evacuee transplanted in Houston and as a physician who lost his medical practice due to the flooding. The Department of State Health Services provided an overview of the Texas response, and the physicians and executives from the large county medical societies described their volunteer efforts at the community level. The counties played a significant role in providing volunteers to care for sheltered hurricane victims.

While Texas' state, regional, and local plans were mostly implemented with success, issues related to communications, special need populations, mass sheltering, and chain of command should be addressed.

Recommendations : The Council on Public Health recommends that TMA:

1. Ask our American Medical Association to work with subject matter experts at the national level to produce a provider manual on medical liability and coverage during disasters;
2. Ask our AMA to work with the American Red Cross to improve plans, protocols, and policies regarding the provision of health care in mass casualty shelters;
3. Request our AMA to develop templates for private practice/office continuity plans in CD-Rom or web-based format with backups to be stored at the state medical association offices;
4. Work closely with the Texas Department of State Health Services (DSHS) in statewide disaster planning efforts and advocate for stronger roles for county medical societies in local disaster planning efforts, drills, and other activities;
5. Establish a liaison to both the Commissioner of Health and the state's emergency coordinator to explore medical needs during terrorism and natural disasters;
6. Work closely with DSHS to establish state-level communications through the Health Alert Network (HAN) and assist local health departments or other appropriate agencies in expanding the mechanism for informing physicians of essential information on a newly recognized outbreaks;
7. Work the DSHS to improve physician reporting and consultation systems at the state and local levels;
8. Work with DSHS to establish standards for local public health departments to ensure that reporting physicians have immediate or rapid access to a public health authority who can provide additional guidance on confirmation and treatment of patients, especially during natural and biological disasters;
9. Work closely with DSHS, in the event of a pandemic or other infectious disease disaster, to ensure that plans minimize the negative impact on the health care community;
10. Maintain a database of volunteer physicians, coordinating with state ESAR-VHP efforts, and including tracking of member participation in other disaster response organizations (e.g., local health facility response, Texas Medical Rangers, Medical Reserve Corps, DMATs, Texas National Guard);
11. Work with DSHS to define when it will be appropriate to contact area physicians and ensure that potential volunteers understand the commitment they are making, including information on liability, travel expenses, job protection, and personal and family safety;
12. Examine state laws governing practice and liability under these various disaster declarations and advocate for any needed legislative changes to address these issues;
13. Work with DSHS to identify specific needs and to deploy physicians and special services to assist with the medical needs of shelter evacuees during a disaster;
14. Recruit physicians in advance of a disaster with particular emphasis on assuring sufficient pediatric and other specialists, including mental health counselors with special efforts to address the specific needs of patients with mental illness, Alzheimers, infectious diseases, long-term care residents, and pregnant women;
15. Encourage local communities to identify, prior to an event, a designated infection control practitioner to provide basic infection control guidance to prevent exposure to or transmission of infectious diseases in temporary community evacuation centers;
16. Educate its members on the essential aspects of terrorism and disaster medicine through CME programs at state society meetings and by articles in state society journals and newsletters with special focus given to training on Incident Command Structure, Basic and Advanced Disaster Life Support, and triage for health care providers;
17. Ensure that physicians understand the circumstances in which quarantine is appropriate and utilized and how to carry out complementary, previously determined roles in their practices regarding surveillance, health care, and public information;
18. Promote the Texas Medical Rangers and the Medical Reserve Corp to physician members;
19. Encourage medical educators at all levels to participate in training physicians in the essentials of disaster and terrorism medicine relevant to their practice and specialty;
20. our county medical societies to appoint a staff member or member physician to coordinate the society's participation in disaster preparedness and to participate in community disaster drills that test these plans;
21. Encourage our county medical societies to maintain an ongoing relationship with their local or regional public health departments and to consider appointing the local or regional public health director to the board of the county medical society as a consultant;
22. Encourage our county medical societies to work with the local health department to compile and maintain a contact list of physicians (both member and nonmember) in the community and to ensure that physician-friendly reporting mechanisms are in place, and that a two-way flow of information exists to provide incentives for physician collaboration;
23. Encourage our county medical societies to provide a venue for physician education, work with sponsors of local CME efforts, and identify members who are particularly interested and may become peer leaders and educators;
24. Encourage our county medical societies to participate in practice drills and exercises that involve local health departments and local emergency response units;
25. Encourage physicians and their staff organizations to advocate for these disaster planning measures in their health care facilities; and
26. Encourage individual physicians to have a strategic plan for everything from evacuating their office building, protecting employees during a communicable disease outbreak, maintaining continuity of their practice and maintaining communication with their families, and provide templates and guidelines for these types of plans to physicians.

REFERENCES

1. American Medical Association . Medical Preparedness for Terrorism and Other Disasters (I-00)

2. Florida Department of Health. Office of the Inspector General. 2004 Hurricane Season After Action Report . March 2005 .

3. Texas Institute for Health Policy Research. Health Policy Brief: Regional and Local Public Health.

4. Texas Institute for Health Policy Research. Health Policy Brief: All Hazards & Medical Preparedness .

5. Texas Office of the Governor. Texas Homeland Security Strategic Plan: Part III State of Texas Emergency Management Plan . February 2004.

6. Texas Office of Homeland Security. Report to the Governor on Texas Hurricane Preparedness . March 17, 2005.

7. U.S. Department of Homeland Security. National Response Plan . December 2004 .

8. U.S. Department of Health and Human Services. Health Resources Services Administration . 2005 Hurricanes: Lessons Learned Report Conference Call Summary - State of Texas. Nov. 15, 2005.

9. U.S. Department of Health and Human Services . Terrorism and Other Public Health Emergencies: A Reference Guide for the Media. September 2005.

10. SUMA/Orchard Social Marketing, Inc . In Case of Emergency: Volunteers in Texas . September 2005.

11. American Medical Association News. Editorial. "The Ethics of Quarantine: Treading Carefully." Dec. 26, 2005.

TMA House of Delegates: TexMed 2006