The Role of Public Health and Health Systems, Facilities, and Providers in Emergency Preparedness and Response

The rural healthcare delivery system provides access to healthcare services, including primary care, mental and behavioral health, emergency care, and public health services. The rural healthcare delivery system consists of rural hospitals, Critical Access Hospitals (CAHs), Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), long-term care facilities, public health agencies, home health agencies, emergency medical services (EMS), and dental practices, among others. The unique public health and healthcare system challenges experienced in rural communities, including provider shortages, weakened rural health infrastructure, and financial limitations of rural hospitals and health systems, are further heightened during public health emergencies. Transformational leadership in rural healthcare systems can support effective and innovative response efforts and drive health equity. Planning and coordination between public health and healthcare systems, facilities, and providers are essential for emergency planning, response, and recovery.

Surge Capacity

Surge capacity is a critical component of healthcare preparedness. The U.S. Department of Health and Human Services Administration for Strategic Preparedness and Response defines surge capacity as:

“Medical surge describes the ability to provide adequate medical evaluation and care during events that exceed the limits of the normal medical infrastructure of an affected community. It encompasses the ability of HCOs to survive a hazard impact and maintain or rapidly recover operations that were compromised (a concept known as medical system resiliency).”

When there is a surge of patients, healthcare facilities are stretched beyond their normal operative capacity. When needed, the U.S. Department of Veteran's Affairs (VA) can provide surge assistance to local communities. Referred to as the VA's Fourth Mission, the VA supports national, state, and local preparedness in response to emergencies and disasters. The VA will fill service and support gaps during emergencies, as it is the “primary medical back-up system” for the Department of Defense.

Response

Depending on the emergency, healthcare providers may be unable to provide the usual standard of care. Rather, they may shift to a “sufficiency-of-care mode” with a focus on saving as many lives as possible. This may involve triaging patients as an approach to identifying whom to care for and when, based on their medical needs and the available resources. In some instances, healthcare facilities may identify patients who need to be transferred to other nearby healthcare facilities to best serve them.

When there is a patient surge during a response, healthcare systems must care for an influx of patients and meet the increased demand for medical services. Some considerations for surge capacity include ensuring adequate:

• Medical personnel – A surge will often require a greater number of medical and healthcare personnel to deliver care and coordinate services. In addition, specific types of emergencies or disasters may increase demand on certain specialist providers. For example, surgeons may be especially in demand following an explosion.
• Physical space and beds – Hospital beds and availability of rooms can be limiting factors during an emergency. Hospitals can establish plans for using both clinical space, such as outpatient rooms, and non-clinical space, such as hallways, to house patients. Discharging patients who are not in need of immediate attention can free up space for patients with more urgent needs. Alternate care sites can also accommodate the surge of patients and can be created in areas more easily accessible to incoming responders.
• Supplies and equipment – During a surge, additional supplies and equipment may be needed to serve the influx of patients. Depending on the type of emergency or disaster, needs may include specialized equipment, including technology, for delivering medical care as well as communications and information sharing.

Partners are essential in supporting surge capacity. Communities can develop plans for engaging partners, such as EMS personnel, healthcare facilities, and other community organizations, to support the increased demand for medical personnel, physical space, and supplies and equipment.

Also, during an emergency, residents from urban areas may evacuate to or through rural areas. This can put added strain on available resources and hospital bed capacity. Rural communities should consider this possibility, as well as potential numbers and characteristics of urban evacuees, in their planning efforts.

The HHS Administration for Strategic Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE) provides resources highlighting lessons learned and promising practices for planning and responding during surge capacity.

If a surge response can no longer maintain typical levels of care, rural hospitals and healthcare systems may shift to crisis standards of care (CSC). The goal of CSC is to achieve the best outcome for groups of patients, rather than individuals. It balances and adjusts resources in response to demand.

Recovery

After an emergency, communities can use data from surveillance measures of the health system's performance during the response to inform efforts to improve the health system's surge capacity for future disasters. It is also important to consider secondary surge capacity during the recovery phase. The specific healthcare needs of populations affected by the emergency or disaster may differ between the response and recovery phase.

Continuity of Care

Ensuring continuity of care for patients with chronic diseases can be challenging during and after an emergency as people evacuate and may be unable to easily access their providers.

Response

There are several preparedness and recovery strategies that can help mitigate gaps in care for patients during a public health emergency.

Patient education and preparedness – It is important to educate patients about healthcare options, make patients aware of potential shelter locations, and ensure patients are stocked and knowledgeable about their medication needs.

Healthcare provider and organization preparedness – This includes establishing communication processes; backing up medical records; acquiring a surplus of supplies and equipment; and building relationships with other local institutions and organizations, like pharmacies and social service agencies.

Provider-patient communication – Depending on the type of emergency, means of communication between providers and patients may be severely altered or limited. However, when possible, healthcare providers can communicate essential information to patients and the public when other means of communication may be disrupted. For patients with caregivers, provider-caregiver communication during an emergency may be critical for ensuring the patient's needs are met if access to their provider is limited.

During an emergency, health systems and providers may need to be innovative to ensure that critical health information is communicated to patients. For example, the COVID-19 pandemic has emphasized the importance of telehealth and telemedicine for reaching patients at home in rural areas. Hurricane Katrina illustrated the need for providers to preemptively document emergency contact information and ask patients to share their disaster plans: for example, where they would evacuate to, in case of an emergency. Providers should also be prepared to disseminate medical information at shelters or temporary clinics, if needed.

Patient safety – The following are strategies for keeping patients safe and secure during an emergency response:

• Putting in place a security team
• Monitoring incoming and outgoing patients and visitors
• Establishing quarantine, decontamination, and isolation areas
• Ensuring emergency access and exit routes are clear and accessible
• Maintaining functioning critical systems such as electricity and water supply

Volunteer and donation management – During a response, healthcare providers and local volunteers may be responsible for managing the acquisition and distribution of donated medical supplies, including medications and personal protective equipment.

Recovery

Hospital visits for ambulatory care sensitive (ACS) conditions is one metric for identifying groups that did not receive adequate and timely access to care during the emergency response. By monitoring health service utilization for ACS conditions, health systems can assess who may have experienced lapses in care during an emergency and can ensure these subgroups receive the care they need during the recovery phase. During the recovery phase, documenting strategies and procedures that supported successful continuity of care during the emergency can improve continuity of care for patients during the next disaster.

Immunizations

The COVID-19 pandemic has forced the United States to seriously examine the country's capacity to produce, distribute, and deliver immunizations during an emergency. The U.S. Department of Health and Human Services (HHS) developed the Operation Warp Speed Strategy for Distributing a COVID-19 Vaccine. The strategy outlined several priority activities to distribute vaccines to all Americans:

• Engaging with state, tribal, territorial, and local partners and other stakeholders to promote vaccine uptake
• Utilizing a centralized and phased approach for distributing vaccines via health departments, federal entities, and commercial partners like pharmacies
• Ensuring distribution sites can store, handle, and safely administer vaccines
• Collecting and monitoring data on distribution and administration of vaccines

Vaccine production uses materials (for example: glass vials, stabilizing agents) that require a stable supply chain and a trained workforce to manufacture the vaccine. By anticipating potential bottlenecks in the supply chain and, if possible, forecasting the demand in advance of an emergency, rural communities may be able to avoid vaccine shortages in the future.

Response

Distribution – Vaccine distribution to rural healthcare systems is heavily dependent on the national approach. During the COVID-19 pandemic, the United States government used a centralized approach to distribute COVID vaccines to attempt to maintain full visibility and tracking of the process across the country. A contracted distributor then supplied the vaccines allocated by the government to state, tribal, and local jurisdictions and authorized partners for delivery. Rural health systems can prepare for receiving vaccines by ensuring their infrastructure, storage capabilities, and other logistics are in place. Tapping into existing networks and engaging partners to ensure that a community receives necessary vaccines are action items to ensure better healthcare for the community.

Delivery – The following strategies can be used to improve vaccine delivery and deployment in rural areas during an emergency:

• Set up mass vaccination sites to increase patient load and minimize management issues across smaller healthcare settings
• Partner with pharmacies and long-term care facilities to leverage existing infrastructure and aid in scheduling appointments, reaching out to community members, storing vaccines, and other logistics
• Partner with the National Guard to administer vaccines and train others in vaccine administration
• Create mobile vaccination clinics to improve access to vaccinations, especially in remote rural communities
• Use community-based settings, such as schools, churches, and fire departments, to administer vaccines, improve access for hard-to-reach communities, and improve vaccine confidence

During the COVID-19 pandemic, rural communities identified innovative strategies to vaccinate community members against COVID-19. For example, in rural Alaska, tribal healthcare providers delivered COVID-19 vaccines to community members via small airplanes, water taxis, and sleds.

Recovery

Lessons learned from vaccine implementation during an emergency response can improve vaccine distribution and delivery strategies to prevent future infectious disease outbreaks. For example, during the COVID-19 pandemic response, rural communities experienced challenges that impeded immunization efforts. These challenges included limited vaccine confidence, access, and uptake in rural areas. The National Governors Association Center for Best Practices (NGA Center) recommends the following strategies for rural communities:

• Build vaccine confidence by delivering transparent and effective communication and messaging campaigns in rural areas
• Ensure access to vaccines for rural populations by adopting approaches that address common rural challenges related to infrastructure, travel distance, and workforce
• Develop equitable and sustainable vaccine allocation and distribution systems for rural communities

During the recovery phase, organizations and agencies like the World Health Organization and the Centers for Disease Control and Prevention may update their vaccine implementation guidance based on lessons learned from the response to ultimately inform future planning efforts. It is important that rural communities consider and include any changes in such guidance in local preparedness planning.

Resources to Learn More

Hospital-Based Emergency Care: At the Breaking Point
Document
Discusses the impact of limited resources and increased patient volume on hospital-based emergency and trauma care during disasters. Topics cover workforce across various disciplines, patient safety, quality and efficiency of emergency care services, information technology, and challenges of providing emergency care in rural locations.
Organization(s): National Academies of Sciences, Engineering, and Medicine
Date: 2007

Hospital Emergency Response Checklist: An All-Hazards Tool for Hospital Administrators and Emergency Managers
Document
Provides information and checklists on key factors necessary to help hospital administrators and emergency managers respond to disaster events. Covers coordination of hospital operations, internal and external communication, safety and security, triage, surge capacity, continuity of essential services, and post-disaster recovery.
Organization(s): World Health Organization (WHO)
Date: 2011

Rural Healthcare Surge Readiness
Document
Resources for rural healthcare systems preparing for and responding to a COVID-19 surge. Includes resources for emergency medical services, inpatient and hospital care, ambulatory care, and long-term care settings. Addresses a wide range of topics including healthcare operations, space, supplies, funding, and more.
Organization(s): COVID-19 Healthcare Resilience Working Group
Date: 7/2020

Rural Health Care Delivery System Assessment Tool
Document
Offers rural healthcare leaders with a systematic approach for assessing their healthcare system's emergency preparedness and response. Topic areas for assessing efficiency and effectiveness include governance and leadership, community engagement, financial health, clinical care, and emergency resilience.
Organization(s): Colorado Hospital Association (CHA), Eugene S. Farley, Jr. Health Policy Center
Date: 5/2021

State Strategies to Increase COVID-19 Vaccine Uptake in Rural Communities
Document
Outlines strategies and considerations to increase vaccine uptake particularly in rural communities including improving access, leveraging trusted messengers, and creating sustainable structures for vaccine delivery.
Organization(s): National Governors Association
Date: 8/2021

Urban to Rural Evacuation: Planning for Rural Population Surge
Document
Reports findings from a study assessing the likelihood of urban evacuation to rural areas in response to a disaster or public health emergency and provides considerations for rural planning and response.
Author(s): Meit, M., Briggs, T., & Kennedy, A.
Organization(s): NORC Walsh Center for Rural Health Analysis
Date: 8/2008