Abstract

Nash and Ramsay present a compelling case for reconsidering methods by which healthcare assets are deployed to reduce the impact of chemical/biological terrorism and highly infectious disease. We concur with the authors' general thesis regarding the need to decentralize the delivery of emergency healthcare services, particularly following an event of the magnitude they describe. The necessity of identifying creative ways to respond to increasingly complex situations of national significance has never been as important as it is at present.  

Nash and Ramsay are to be congratulated for their willingness to engage others in thoughtful discussion. We write here in response to the authors' proposal; offer our observations on similar strategies currently employed in the United States; and suggest an area in which the authors' concepts might be adapted.

Parallels in United States Public Health

Central to Nash and Ramsay's proposal is the ability for non-physician healthcare personnel to make rapid, accurate triage and assessment decisions. A parallel recent proposal in the US would increase the scope of practice for many pre-hospital emergency care providers. However, Schmidt and colleagues (2000) determined that despite protocols to assist emergency medical technicians (EMTs) in making pre-hospital determinations regarding the need for transportation to a hospital, "from 3% to 11% of patients determined on scene not to need an ambulance had a critical event." A similar study concluded that "paramedics using written guidelines fall short of an acceptable level of triage accuracy to determine disposition of patients in the field" (Pointer et al. 2001). Such findings suggest that there needs to be more rigorous review of pre-hospital providers' capabilities for making the types of determinations proposed by Nash and Ramsay. In the United States, there is ongoing research to identify effective strategies by which healthcare assets might be more effectively deployed following a wide-scale disaster. We also suggest that there be similar studies to evaluate the abilities of other allied health providers (e.g., nurses, physicians' assistants, etc.) to make more accurate triage decisions.

The American public health system has enjoyed success with previous efforts to decentralize certain services. For example, public health agencies have recently begun offering "drive-thru flu vaccination clinics" in order to increase the participation in immunization of at-risk citizenry. Under such programs, patients literally "drive through" a portable tent staffed by public health nurses, and participants are immunized without ever getting out of their cars. Similar programs have been used for cholesterol screening, free blood pressure measurement and many other wellness/preventative services. Success with such decentralized programs bodes well for further applications consistent with Nash and Ramsay's model.

Other Considerations

Nash and Ramsay raise important issues regarding the limitations to their proposal. We agree that the logistics of quarantine will be important drivers in the efficacy of any decentralized approach to delivering disaster medicine. In addition, however, we are concerned that the strategies they offer for the various decentralization scenarios may need additional refinement for several important reasons.

First, there is the phenomenon of the "worried well." According to Beaton et al. (2005), in the hours and days following the Aum Shirinkyo's release of sarin gas in the Tokyo subway system, the vast majority of patients self-triaged themselves directly to local emergency departments. Moreover, the "worried well" - who were psychologically but not physiologically affected by the sarin - outnumbered true patients by a ratio of 4:1 (Beaton et al. 2005: 108). The impact of these physically well patients on individual facilities overwhelmed hospitals' surge capacity.  

Citing Auf der Heide's 1996 findings, Beaton et al. (2005) note that self-triage to healthcare facilities begins almost immediately after a disaster event, "with most of the casualties arriving at nearby hospitals on their own, in non-emergency vehicles within an hour and a half of the disaster impact" (105). Even though we readily agree with Nash and Ramsay that it is far more effective to treat only those who require medical attention (and, ideally, to treat them in the least expensive setting), early and effective public information and communication will be critical components of keeping patients - both real and the "worried well" - from self-triaging to hospitals; if the communication of this information is not available in a timely fashion, it will undercut any strategy to treat patients in their homes.  

Second, surveillance systems currently employed to isolate and identify widespread epidemiological outbreaks are not yet sophisticated enough to immediately detect and identify many of the biological agents that would likely affect a populace. Infection with many weaponized biological agents will likely present as generalized flu-like symptoms. By the time large numbers of patients are identified (e.g., by monitoring admissions to hospital emergency departments, absenteeism from school or work or visits to private physician offices), the spread may well be such that it will be impossible to control mass self-triage such as that described by Auf der Heide and Beaton et al. (1996). Nevertheless, continuous efforts to improve surveillance and monitoring are critical, and it will be difficult to base a "care-in-place" strategy on these systems until they are more effective.

Third, incidents involving chemical and biological terrorism will require decontamination of affected patients prior to their receiving definitive medical care. The equipment required for thorough decontamination is both expensive and complicated. We have some concern that implementing individualized decontamination may prove more challenging than the authors assume.

Potential Adaptation

Despite our concerns, we recognize that Nash and Ramsay have proposed a concept that has numerous possibilities for adaptation. One such adaptation might build on the concept of "sheltering-in-place," which has been discussed at length in the disaster management literature. (See, for example, Sorenson et al. 2004.) According to the "shelter-in-place" practice, instead of evacuating citizens to a remote location, those affected by a disaster are provided with food, water, shelter and other required provisions on-site, while disaster recovery occurs around them. In these cases, healthcare professionals and medical assets are frequently deployed directly to the sheltered locations, in effect executing Nash and Ramsay's concept of bringing healthcare to those in need. The difference is that the deployed assets are brought to locations containing large numbers of patients in need instead of going house to house to see patients in individual settings. We feel that adapting Nash and Ramsay's concept to larger gatherings of isolated (versus "quarantined") patients would reflect a modification of current practices by which "sick call clinics" are set up near large shelters for evacuated patients.  

Conclusion

Nash and Ramsay provide thought-provoking strategies to decentralize the response to large-scale medical disasters. An all-hazards approach to disaster management requires careful coordination of medical assets that is capable of delivering effective healthcare to affected individuals. The authors are quite correct in their observation that highly contagious or biologically contaminated patients could pose a clear danger to entire regions of the world. Even though we see some operational challenges to implementing a house-to-house approach, we feel Nash and Ramsay have correctly framed the need to bring healthcare to patients during major adverse events. We hope that more strategies that might accomplish this objective, maximizing centralized medical expertise and logistical convenience without sacrificing the ability to leverage economies of scale, can be identified. We encourage additional thoughts for developing and implementing adaptations to their proposal.

About the Author

J. Bennet Waters, DHA, MPH, is Deputy Director of Executive Programs and Clinical Assistant Professor in the Department of Health Policy and Administration, School of Public Health, University of North Carolina at Chapel Hill. E-mail: jbwaters@email.unc.edu.

Steven G. Justus, MD, FACEP, is a practising emergency physician and for 18 years has served as President of a 70-provider multi-specialty physician group in Charlotte, NC. Dr. Justus is also an Adjunct Assistant Professor in the Department of Health Policy and Administration, School of Public Health, University of North Carolina at Chapel Hill.

Acknowledgment

The authors wish to thank Drs. Jim Porto and Laurel Files for their willingness to offer thoughtful comments, suggestions and editorial input. Their participation significantly improved our commentary.

References

Beaton, R., A. Stergachis, M. Oberle, E. Bridges, M. Nemuth and T. Thomas. 2005 "The Sarin Gas Attacks on the Tokyo Subway - 10 Years Later / Lessons Learned." Traumatology 11(2): 103-19.

Pointer, J.E., M.A. Levitt, J.C. Young, S.B. Promes, B.J. Messana and M.E.J. Adèr. 2001. "Can Paramedics Using Guidelines Accurately Triage Patients?" Annals of Emergency Medicine 38(3): 268-77.

Schmidt, T., R. Atcheson, C. Federiuk, N.C. Mann, T. Pinney, D. Fuller and K. Colbry. 2000. "Evaluation of Protocols Allowing Emergency Medical Technicians to Determine Need for Treatment and Transport." Academic Emergency Medicine 7(6): 663-69.

Sorenson, J.H., B.L. Schumpert and B.M. Vogt. 2004. "Planning for Proactive Decision Making: Evacuate or Shelter in Place?" Journal of Hazardous Materials 109(1-3): 1-11.