Life Support

ast Feb. 17, with the Washington metropolitan area under a state of emergency after a blizzard pounded the region with more than 2 feet of snow, Karin Kerby may well have averted a far more serious calamity. Kerby, a nurse at Loudoun Hospital Center in suburban Virginia, arrived for her shift in the emergency room about 6:30 a.m., the same time an ambulance crew was depositing an elderly woman in a hallway in the overcrowded ER. The woman was having trouble breathing and appeared to have severe pneumonia. "You could just glance at this patient and know that she was very, very ill," Kerby says.

Kerby's job that day was to prioritize treatment for patients arriving by ambulance and the woman quickly became an urgent concern. Because the ER was full of patients who had been stranded by the snowstorm, it was about 15 minutes before Kerby could move the woman into a treatment room where she could be put on oxygen. In what would later seem like a stroke of good luck, that room was the ER's negative-flow room-a room in which negative air pressure is maintained to prevent the escape of disease-causing microbes. Even without fully activating the room's ventilation system-a step the staff later took after learning more about the patient, who didn't speak English-the pressure probably was sufficient to help contain any contagions, Kerby says.

A couple of hours later, the woman's nephew phoned the ER and told Kerby that his aunt had recently returned from a visit to China. According to family members in China, health officials there were grappling with an outbreak of a strange, flu-like illness. Kerby's antennae immediately went up. Because the hospital is close to Dulles International Airport and serves a cosmopolitan patient population, she regularly scours newspapers and the Internet for any information on outbreaks of disease. A few days earlier, she had read a brief item in The Washington Post about an atypical pneumonia spreading in China.

"When I got off the phone with [the patient's] nephew, I said to the doctor, 'This is the story, let's put her in isolation,'" Kerby recalls. The attending physician immediately agreed, and, following a protocol Kerby helped write months earlier for responding to acts of biological terrorism, the doctor notified an infectious disease specialist and Kerby notified the local health department, which in turn notified the Virginia Department of Health and the federal Centers for Disease Control and Prevention in Atlanta. Officials at those agencies immediately began compiling a list of people with whom the patient had come in contact, and, within hours, began checking the health status of those people, including health care workers.

Kerby, who had flown to Texas shortly after her encounter with the patient, received a midnight call from a hospital administrator, calling on behalf of the CDC, who wanted to know whether she had any symptoms of illness. It was Kerby's first experience with CDC monitoring, and she was struck by how quickly the agency reacted. "This was before we knew what [disease] this was. That week, they were in contact with every health care worker that had come in contact with [the patient]. They tracked me down in Texas and they went to the home of one of the nurses who was in Southern Virginia. There is a system in place, and it works," she says. At least a couple of health care workers were placed in voluntary quarantine until they were deemed free of illness.

Only weeks later would health officials around the world come to understand the threat posed by Severe Acute Respiratory Syndrome, or SARS, the deadly viral disease that emerged from China last winter and has spiraled out of control at hospitals in China, Hong Kong, Taiwan, Vietnam, Singapore and Toronto. The highly contagious disease has killed hundreds, sickened thousands, forced tens of thousands of people into quarantine, and has had devastating economic consequences across Asia and Canada. Kerby's patient last February is believed to have been the first case of SARS in the United States, and many believe the hospital staff's quick response likely spared many people from contracting the disease, which has spread particularly rapidly through hospitals. The patient eventually recovered, and, although two family members probably contracted mild cases of SARS, both recovered on their own and neither is believed to have passed on the disease to anyone else. In addition, the actions taken by Kerby and other staff members at Loudoun alerted health care officials across the country to a new disease emerging from China. By the end of May, 65 SARS patients had been reported in the United States. Thirty-two had recovered from the disease, and none had died, although death rates elsewhere have ranged from about 6 percent to more than 50 percent in some patient populations.

LUCK AND HARD WORK

What's notable about the first SARS patient in the United States is that Kerby alerted public health authorities to the patient's symptoms before anybody could know how serious the situation was. She did so not because she was required to notify anyone, but because she had a hunch based on years of experience, her diligence in keeping track of global medical news, and the information provided by her patient's family. While every physician and laboratory is required by law to report specific diseases and medical conditions to public health authorities, by the time those diseases are definitively diagnosed, patients often will have had ample opportunity to spread the disease. "Remarkably, this system generally works," David Fleming, deputy director for public health science at the CDC, told members of the House Government Reform Committee in May. Nonetheless, Fleming acknowledges that the success of the nation's disease surveillance system has as much to do with the competence of health care workers such as Kerby as it does with any system.

Donald A. Henderson, a special adviser to Health and Human Services Secretary Tommy Thompson, says the relationships among health care workers at the federal, state and local levels have improved significantly since the anthrax attacks in the fall of 2001, and those improvements have directly contributed to the thus-far successful response to SARS in the United States.

The anthrax attacks, which have never been solved, resulted in 23 cases of the disease and five deaths, all on the East Coast. Despite the relatively small number of cases, "it was terribly disruptive," Henderson says. The attacks spurred many hospitals and public health organizations across the country to refine or develop plans for dealing with bioterrorism. The attacks also prompted organizations that would be involved in combating bioterrorism to work out roles and responsibilities and prioritize investments in public health.

The federal government has begun making those investments in the form of grants to hospitals and state and local health departments for training, hiring epidemiologists and other skilled staff, improving disease surveillance and communications, and a range of other initiatives designed to beef up the response to terrorism. Last year, states and cities received $918 million from federal agencies, primarily HHS, to improve their ability to handle biological attacks. As a result, hospitals and health departments are improving their capacity to respond to other health emergencies, especially emerging infectious diseases.

"We have to recognize that with [diseases such as] SARS and West Nile virus, which could be released by man or produced by nature, the problems we face are [the same]," Henderson says. "We're now doing what we should have been doing anyway," he says.

Kerby was involved in developing Loudoun Hospital Center's bioterrorism response procedures after the anthrax attacks. The procedures served the hospital well in its first encounter with SARS. "Our systems worked well," Kerby says. Not only did the hospital have procedures in place for responding to an unknown, infectious disease, but hospital workers knew those procedures and had strong working relationships with officials in the Loudoun County Health Department. By quickly isolating the patient and informing public health officials at the local, state and federal levels, the hospital staff set in motion a system designed to thwart the spread of disease, no matter what its cause.

Still, Kerby is acutely aware that the situation might have turned out very differently. Unlike many hospitals across the country, Loudoun has recently managed to overcome a severe nursing shortage. "We are almost full staff, for the first time in a long time, which is fairly rare. The last couple of years we had massive turnover and a lot of temporary agency staff, which makes it very difficult for education to be done. Communicating this information [such as the procedures for responding to bioterrorism] is not easy, even among hospital staff," she says.

A host of factors contributed to the hospital's ability to successfully respond to SARS: For one thing, the patient had essentially been isolated at home for days before she arrived at the hospital, by which time she may not have been as contagious as SARS patients elsewhere. Her family was proactive in informing medical personnel about her condition and in relaying information from China, where the government was then withholding information about the disease. Emergency room personnel at Loudoun have been well trained to cope with smallpox, another infectious disease, and more recently had dealt with more exotic diseases than personnel in many other regions as a result of local outbreaks of West Nile virus and malaria and the 2001 anthrax attacks. The Loudon staff also had resources, including a specially ventilated room, that many emergency rooms lack. It's also significant that Kerby, an alert nurse with 25 years of experience at Loudoun Hospital Center, was among the first health care workers to treat the woman.

"So much of this rests on the shoulders of an individual nurse or doctor," says Kerby, at a time when hospitals and clinics across the country are short of skilled medical personnel, especially nurses, and medical staffs routinely work long hours and operate under tremendous pressure. "I see that as the loophole through which this virus will possibly explode," Kerby says.

CRITICAL NEEDS

The health care system, to the extent that it is a system at all, is largely a state, local and private affair, funded with both public and private money. Historically, hospitals and private physicians have competed for patients (and the federal and private health insurance funds they bring) and had relatively informal relationships with public health departments, through which they are required to report cases of certain diseases, such as tuberculosis, a contagious respiratory infection. While emergency medical response personnel typically have trained with firefighters and police when preparing for terrorist attacks, hospitals and individual physicians rarely took part in such training exercises. After Sept. 11 and the anthrax attacks a month later, it became clear that any effective response to terrorism would have to involve hospitals, medical personnel and public health departments.

The Health and Human Services Department, primarily through subordinate agencies, including the CDC and the Health Resources and Services Administration, has brought much-needed funding and planning to private, state and local efforts. Still, efforts to bolster the medical response to a bioterrorist attack are in the early stages and many loopholes remain through which any number of deadly microbes might slip. Shortages of critical personnel, especially nurses, epidemiologists and laboratory technicians, could greatly impede a hospital or health department's response to an outbreak. The epidemiologists and laboratory personnel are critical to identifying and containing an outbreak early on, and nurses are needed to care for victims and administer drugs or vaccines.

Besides shortages of key personnel, many hospitals, clinics and health departments lack adequate laboratory facilities and equipment for responding to a bioterrorist attack or an outbreak of infectious disease, whose results likely would be the same. Equipment, such as ventilators, and personal protective gear, including masks, gowns, gloves and goggles-all of which are required for treating most SARS patients-are in short supply in many places.

Add to these variables a fallible disease surveillance system, under which early detection of potentially devastating medical conditions, including anthrax in 2001 and SARS earlier this year, occurs as much as a result of quick-thinking medical personnel as of any comprehensive reporting mechanism, and it's easy to see why terrorism experts are nervous. What's more, it will take unprecedented cooperation between private health care workers and institutions; local, state and federal government coordination; and an enormous amount of money to shore up the public health system with skilled workers, improve the capacity of laboratories and hospitals to respond to infectious disease outbreaks and institutionalize effective surveillance to not only monitor diseases after they are diagnosed, but symptoms of disease as they emerge in the population. The nearly $1 billion spent by the federal government thus far is just a fraction of what will ultimately be needed to revive the long-neglected public health system.

The fissures in public health were starkly evident during the 2001 anthrax attacks. In an April survey of state and local preparedness for bioterrorism, the General Accounting Office found that despite fewer than two dozen actual cases, public worry about anthrax was so great that it was necessary to test more than 70,000 suspected anthrax samples in laboratories across the country. "Public health laboratories in some areas quickly ran out of space for testing and storing samples. State and local officials had to rely on laboratory assistance at the federal level, and the CDC received more than 6,000 anthrax-related samples," forcing it to operate around the clock, GAO found (GAO-03-373). In addition, 85 percent of state and territorial public health laboratories reported that the requirements of anthrax testing delayed routine testing for tuberculosis, sexually transmitted diseases and other infectious diseases-diseases that were a far greater threat to public health than anthrax.

While the CDC published protocols for dealing with suspected anthrax samples, many health facilities couldn't print the files because they lacked adequate Internet connections. GAO auditors visited one state where a state public health official ended up driving 500 miles to deliver the protocols by hand.

WANTED: SKILLED PERSONNEL

Improving the prognosis for public health rests on many factors. A vital one is hiring enough nurses, epidemiologists and laboratory technicians to end long-standing shortages. In some cases, there simply aren't enough people with the right skills available to fill existing job openings. In addition, many public health departments cannot afford to attract and keep people with the best qualifications-there are too many higher-paying jobs in the private sector.

A wide-scale shortage of nurses has been well documented and data suggest the trend will not easily be reversed. The Health Resources and Services Administration last July estimated that at least 30 states had a shortage of registered nurses, a trend expected to increase over the next two decades. According to the American Hospital Association, the vast majority of job vacancies in hospitals are for nurses. Nursing schools report a decline in student enrollments, the number of first-time nursing-school graduates who sit for licensure exams has dropped more than 30 percent since 1995, and the average age of registered nurses continues to climb. GAO estimates that by 2010, more than 40 percent of all registered nurses will be older than 50.

The nursing shortage has important implications. Numerous studies have shown a direct correlation between nursing staff and health outcomes. An August study of patient deaths at more than 1,600 hospitals by the Joint Commission on Accreditation of Health Care Organizations found that low nursing staff levels contributed to patient deaths in 24 percent of the cases. There is little doubt that a shortage of nurses would make it that much more difficult to diagnose and respond to a bioterrorist attack involving an influx of sick patients.

The situation for epidemiologists is equally discouraging. A March study by the Council of State and Territorial Epidemiologists found that the number of full-time epidemiologists has remained constant over the last decade, despite a significant expansion of requirements for epidemiological work. The study, "National Assessment of Epidemiologic Capacity in Public Health: Findings and Recommendations," which the CDC partly funded, reported that more than 40 percent of epidemiologists in state and territorial health departments lack formal academic training in epidemiology and few are engaged in research. Not surprisingly, the study found substantial disparities among states in terms of their capacity for disease surveillance.

In addition to helping prepare for bioterrorism, epidemiologists are needed to provide surveillance for West Nile virus infections, analyze trends in hepatitis C infections and monitor changes in the prevalence of antibiotic resistance to multiple organisms-all vital aspects of improving public health and containing serious outbreaks of disease. The study also found that many outbreaks were not investigated because of delays in notification. "While this might be attributed to shortcomings of surveillance systems, it might also be indicative of shortcomings in diagnostic laboratory capacity that could significantly delay or preclude disease reporting," the study found.

Recognizing severe shortcomings in public health laboratory capacity, Congress last year appropriated $146 million in emergency funding to improve state and local public health laboratories. While some of the money was intended to be used to hire laboratory workers, "the needed workforce does not exist," according to a study by the Association of Public Health Laboratories, which said, "The nationwide shortage of skilled laboratorians cannot be addressed through short-term funding support, but requires a long-term national strategy."

MONEY WOES

While a cash infusion won't cure everything ailing the health care system, it would go a long way toward speeding recovery, especially for hospitals struggling to control skyrocketing operating costs and prepare for potential terrorist attacks, all while state and federal funding is drying up. Susan Waltman, senior vice president and general counsel of the Greater New York Hospital Association, says hospitals in New York state suffer the worst financial conditions of hospitals anywhere in the country, despite the fact that New York hospitals' adjusted cost and price per patient discharge (national indicators of hospital efficiency) are among the lowest nationally.

The situation in New York is the result of several factors, including the state's previous rate-setting system, declining revenues from insurers, the burden of caring for 3 million uninsured residents, Medicare cuts imposed by the federal Balanced Budget Act of 1977, and additional Medicare cuts to teaching hospitals in 2002, Waltman says. In addition, New York hospitals were particularly hard hit by the Sept. 11 attacks and the subsequent, costly efforts to improve emergency preparedness at hospitals. "The total cost of responding-or standing ready to respond-to the events of Sept. 11 was in excess of $240 million for New York City-area hospitals alone," she says.

Things likely will grow worse for New York hospitals before they get better. To offset budget shortfalls, the state has proposed new taxes and cuts in Medicaid payments that the association estimates will further reduce hospital revenues by $850 million a year-more than $650 million of which would come from New York City hospitals. To date, the only federal assistance New York City hospitals have received has been in the form of $40,000 per hospital in bioterrorism preparedness grants. Hospitals expect to see more federal funding this year, but the amount, "though appreciated, barely begins to scratch the surface in terms of need," Waltman says.

The American Hospital Association estimates it would take $11 billion to fund the nation's 5,000 hospitals' terrorism-preparedness needs, says Alicia Mitchell, an AHA spokeswoman. Last year, federal funding for hospital terrorism-preparedness programs was $125 million. This year, Congress has authorized about $500 million.