key: cord-0009343-ib5mrt1k
authors: Oliver, Anthony L.; Poplin, Gerald S.; Kahn, Christopher A.
title: Emergency Medical Services and 9-1-1 pandemic influenza preparedness: a national assessment
date: 2012-02-03
journal: Am J Emerg Med
DOI: 10.1016/j.ajem.2011.11.014
sha: 877ae1fbca08d138b73fbc7943d76ca119e69602
doc_id: 9343
cord_uid: ib5mrt1k

nan

prophylaxis in nonsurgical patients, we performed a crosssectional study by collecting data of 875 patients, hospitalized in 23 internal medicine and 10 emergency medicine units of 21 different institutions of Lazio, Italy. The physicians of the participating units were requested to provide information, filling in a data form, which included for each patient, the items considered by the Chopard and Kucher score systems [1, 2] as well as by the recommendations of the ACCP08; in addition, also the single bed rest criterion was considered [3] . Seven hundred forty-two forms (84.8%) contained all the requested information and were included in our analysis. The percentage of patients considered at risk by the 4 methods was markedly different. The Kucher and Chopard score systems, respectively, considered 12% and 55% of our patients at increased risk; intermediate values were found using the ACCP08 criteria (16%) and immobilization (29%). The different percentage and distribution of patients considered at risk by the different systems are well displayed in the Venn diagram ( Fig. 1) , which shows that the Chopard score comprises all subjects meeting the ACCP08 and Kucher criteria and part of those immobilized.

On the other hand, immobilization only marginally overlaps with the other criteria. The discrepancy of risk evaluation based on score systems and criteria used in the sample can partially account for the wide heterogeneity existing on risk estimation and use of pharmacological prophylaxis in medical patients.

We express our heartfelt thanks to Professor Enrico Bologna. Emergency Medical Services and 9-1-1 pandemic influenza preparedness: a national assessment

To the Editor,

The likelihood of an influenza pandemic places public agencies under pressure to ensure readiness for local outbreaks. Emergency Medical Services (EMS) is a critical infrastructure that needs to be part of preparedness and response planning for a severe pandemic. Legal and regulatory frameworks should recognize prehospital capabilities as lawmakers attempt to facilitate capacity-building collaboration, which is critical to disaster response. The prehospital system's lack of surge capacity has been detailed [1] [2] [3] [4] [5] , and agencies seek direction regarding preparedness planning from state agencies [6, 7] . The goal of this study was to describe state-level EMS and Public Safety Answering Points (PSAPs) (where 9-1-1 calls are answered) pandemic influenza preparedness. These results are especially timely as U.S. policy makers begin to discuss necessary changes to the Pandemic and All-Hazards Preparedness Act [8, 9] .

During 2008, a cross sectional assessment was administered to public health officials of the 50 U.S. states, 5 territories and the District of Columbia (DC) to determine the extent of state compliance with federally established guidelines for pandemic influenza preparedness [10, 11] . States were asked to provide supporting documentation to substantiate each response. Reviewers examined the submitted documentation and assigned a score for each question based on the criteria shown in Table 1 . Scoring consisted of an ordinal scale describing the level (or completeness) of response for each state's submitted documents and their appropriateness in supporting the activity addressed. Although these results detail preparedness efforts prior to the 2009 H1N1 pandemic, information collected post-2009 H1N1 indicates that these results are still valid [12] . However, these data fail to characterize 9-1-1 preparedness. Furthermore, the role of EMS in the 2009 H1N1 response was limited to assisting with vaccination efforts [13, 14] .

Completed assessments were submitted by 52 (93%) and 45 (80.4%) of the EMS and 9-1-1 respondents, respectively. The EMS activities which states most frequently completely addressed (modal score of 3) were having: 1) requirements or recommendations for basic infection control procedures, and 2) effective, reliable interoperable communications system ( Table 2 ). The activity that was most frequently not addressed was defining the role of EMS providers in "treating and releasing" patients without transport to a healthcare facility. Similar results were found by a post 2009 H1N1 assessment which showed that many of the same EMS preparedness elements needed continued attention [12] . Furthermore, published material describing the role of EMS in the 2009 H1N1 response has so far only detailed the use of EMS personnel to assist with vaccination outreach to the population [13, 14] .

The 9-1-1 activities that states most frequently only minimally addressed included having: 1) a consistent statewide mechanism for communications of updates to PSAPs; 2) a mechanism and protocols in place to coordinate information with PSAPs, and 3) a mechanism to disseminate rapid updates to pandemic influenza symptom set to PSAPs ( Table 3 ). The activity most frequently not addressed was having protocols and procedures in place to guide PSAP triage and patient classification.

Few states had complete or actionable plans defining the role of either EMS or 9-1-1 in pandemic influenza planning. However, more states had developed plans and procedures defining the role of EMS during an influenza pandemic than for 9-1-1. In addition, there were key elements of all-hazards disaster preparedness without substantial planning. For example, protocols allowing EMS personnel to treat and release patients with conditions not requiring transfer to a healthcare facility were notably absent thus potentially limiting the healthcare system's ability to help prevent surge at medical facilities during a severe pandemic. These findings are consistent with reports demonstrating the need for better integration between EMS and the rest of the healthcare community [15] [16] [17] [18] [19] [20] .

EMS will play an essential role during a pandemic in many ways, including providing emergency treatment. Previous disease outbreaks have demonstrated that healthcare personnel have an increased risk of contracting respiratory illnesses [21, 22] and that aggressive respiratory interventions utilized for common prehospital conditions can further increase the risk of disease transmission [21] [22] [23] [24] . Findings that the majority of states had not begun planning to address the isolation and quarantine of EMS professionals (most frequent score of 1) could seriously impact EMS systems. Ensuring EMS workforce health and minimizing health risk is essential to supporting their role in mitigating and responding to an infectious disease outbreak. During the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak, Toronto encountered significant operational problems in providing EMS services when approximately half of the city's prehospital personnel required quarantine [25] . This outbreak also demonstrated that the ability to rapidly provide medically supervised screening of EMS personnel and plan for subsequent quarantine or precautionary symptom surveillance is a vital component of protecting paramedics' health and welfare [25] .

The findings that only 13.3% of states had complete or actionable plans involving PSAPs in statewide pandemic planning is consistent with previous reports demonstrating that 9-1-1 authorities have not consistently been included in emergency planning activities, potentially resulting in delaying the full response to an incident [26] . This exclusion, coupled with technological enhancements and a heightened awareness of the public safety benefits of emergency call centers, have led to recommendations that call centers be included in emergency response planning, and that policymakers enact processes to integrate 9-1-1 with emergency response programs [27] . As 9-1-1 technologies have advanced, many have realized the potential benefit of integrating 9-1-1 into a wider emergency communications safety net. The benefits of which include enhanced situational awareness to coordinate multiple agency operations, thus improving command and control.

Historically, emergency response operations have been adversely impacted by a lack of information sharing and confusion over responsibilities among involved agencies. Furthermore, communication problems can adversely affect patient outcomes, even resulting in death [28] . Effective hazard mitigation often requires a rapid response capability with little room for coordination difficulties [29] . This underscores the need for response agency participation from the early stages of planning, and a clear understanding of the roles and expectations during an incident. This study's finding that only 13.3% of states had complete plans delineating the role of 9-1-1 during a pandemic further demonstrates the absence of 9-1-1 from emergency planning. Many transports to Emergency Departments (EDs) are for non-emergency problems [30] [31] [32] [33] . During a pandemic the use of alternate approaches to divert non-emergent patients Has the State defined the role of EMS providers in "treating and releasing" patients without transporting them to a healthcare facility?

1

Has the State identified strategies to assist local EMS agencies with the protection of the EMS and 9-1-1 workforce and their families during an influenza pandemic?

1 Does the State have requirements or recommendations for EMS agencies for basic infection control procedures? 3 Does the State have system-wide processes for providing vaccines and anti-viral medication to EMS personnel? 2 Have State EMS agencies and public health agencies identified mechanisms to address issues associated with isolation and quarantine of EMS personnel?

1

Has the State defined processes to supplement local EMS agencies in offering support services, including mental health services, to EMS personnel and their families during an influenza pandemic? 1 a 0 = Response missing or documentation does not address activity. 1 = Documentation indicates only intention or beginning of planning for activity, or activity only partially addressed. 2 = State has largely addressed activity, but response is not complete or actionable. 3 = Documentation indicates actionable plan. could be utilized. Utilizing a triage and classification system can reduce the number of EMS responses, transports, and ED visits, and without adversely affecting patient outcomes [34] . The implementation of a medically safe and appropriate emergency number triage system will be critical to a state's ability to reduce the anticipated surge of requests for both prehospital and hospital care during a severe pandemic. Once triaged, a 9-1-1 caller may be directed to varying options for assistance given locally available resources, including instructions for home care; referral to a primary care provider, to community services (e.g., poison control), or to urgent care clinics. Furthermore, a PSAP triage and classification system can effectively guide EMS equipment and transportation resource usage, thereby lessening the drain on EMS resources during a patient surge [35] . The absence of telephone triage protocols to guide 9-1-1 callers to alternate call centers represents a potentially missed opportunity to consistently and systematically decrease the demand for EMS and ED services during a severe pandemic.

Through this national assessment, the majority of states, territories and D.C. were shown to have incomplete plans defining the role of EMS and 9-1-1 in preparing for, mitigating and responding to an influenza pandemic. More states had plans and procedures defining the role of EMS during an influenza pandemic than defining the role of 9-1-1. Investment in focused preparedness areas ought to promote more comprehensive plans toward specific assessment criteria. 

Does the state define isolation and quarantine policies and procedures for PSAPs? 1 Does the state define system-wide processes for vaccinating 9-1-1 personnel, as an element of the critical infrastructure? 0 Does the state identify mechanisms for freedom of movement of PSAP personnel? 0 a 0 = Response missing or documentation does not address activity. 1 = Documentation indicates only intention or beginning of planning for activity, or activity only partially addressed. 2 = State has largely addressed activity, but response is not complete or actionable. 3 = Documentation indicates actionable plan.

This study presents a conceptual framework for the development, application, and evaluation of EMS and 9-1-1 preparedness measurements at the state-level. Results outline a necessary baseline to help guide the evaluation of overall preparedness and effectiveness to pandemic influenza, and lend credence to continued enhancement of data acquisition capabilities for more detailed assessments in the future. Most important, this study provides the impetus for improved collaboration among public health, emergency management, emergency medical services and 9-1-1 in pandemic influenza outbreaks or other public heath emergencies.

Hospital based emergency care: At the breaking point

Frequent overcrowding in U.S. emergency departments

Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations of the Working Group on Emergency Mass Critical Care

Concept of operations for triage of mechanical ventilation in an epidemic

Health Care Facility and Community Strategies for Patient Care Surge Capacity

Weapons of mass destruction events with contaminated casualties

Hospital prepardness for victims of chemical or biological terrorism

Pandemic and All-Hazards Preparedness Act, Pub L No. 109-417, §101 et seq

Plenary Session: Engaging in a Community Dialog: Reauthorization of the Pandemic and All-Hazards Preparedness Act

EMS Pandemic Influenza Guidelines for Statewide Adoption

Preparing for Pandemic Influenza: Recommendations for Protocol Development for 9-1-1 Personnel and Public Safety Answering Points

National Association of State Emergency Medical Services Officials. The National EMS Pandemic Influenza Preparedness Index

The Novel Influenza A H1N1 Epidemic of Spring

Rural responses to H1N1: A flexible model for community collaboration

Current emergency medical services workforce issues in the United States

Change the scope of practice of paramedics? An EMS/public health policy perspective

A medically wise approach to expanding the role of paramedics as physician extenders

Evidence of the effectiveness of health sector preparedness in disaster response: The example of four earthquakes

Reversible roles or territorial imperatives

London ambulance service needs more treatment

Case clusters of the severe acute respiratory syndrome

A cluster of cases of severe acute respiratory syndrome in Hong Kong

Is SARS just ARDS?

Toronto emergency medical services and SARS

Congressional Research Service report to Congress: An Emergency Communications Safety Net: Integrating 911 and Other Services

Final Report of the National Commission on Terrorist Attacks Upon the United States, Official Government Edition

The World Trade Center attack. The paramedic response: an insider's view

Ready or Not: Protecting the Public's Health From Diseases

Comparison of ambulance dispatch protocols for non-traumatic abdominal pain

The emergent problem of ambulance misuse

Medically unnecessary pediatric ambulance transports: a medical taxi service?

Inappropriate use of emergency medical services transport: comparison of provider and patient perspectives

Emergency medical services telephone referral program: an alternative approach to nonurgent 911 calls

Pandemic Influenza: Is Your PSAP Prepared? Emerg Number Prof Mag