When large numbers of people in your community are very sick, the last thing you want is for your hospital to be incapacitated as well. In America, any hospital or emergency room is considered a “first receiver.” That is, in the event of any kind of a healthcare disaster or mass casualty event, they would be the first to receive patients. Therefore, hospitals must be able to work as health care providers and, to some degree, as hazardous materials (hazmat) operators. But setting up hazmat operations can cost up to $2 million, training decontamination teams can cost up to $250,000 in the first year, and running the required disaster drills twice a year, every year, can run anywhere from $125,000 - $250,000. Federal funding for these efforts has been scarce. So most private institutions have been left with two choices: Paying for equipment and training out of pocket, or not doing anything.

For small and rural hospitals, spending this kind of money for disaster preparedness has been difficult. But poor hospital response to Hurricane Katrina and other disasters, and the specter of pandemic flu on the horizon in the next 3-6 years, lead the Joint Commission on Accreditation of Health Care Organizations (JACHO) and the federal government to begin enforcing longstanding rules about disaster preparedness for hospital accreditation. These rules include twice yearly disaster drills and the ability to be a first receiver.

Additionally, communities have been receiving Homeland Security funds to use for training, drills and equipment purchase since 2002. And yet 2005 data shows that almost every community in the United States is no better prepared in 2005 than they were in 2000. Many don't spend what they receive, or they purchase equipment that they aren't trained to use properly. How do you know if your local hospital is up to snuff as a first-receiver facility? Every individual citizen needs to ask the following five questions of their community's healthcare institutions:

Question #1: What has been done to prepare?
If your community is in an area where a natural disaster or an industrial accident could occur, is your hospital conducting live disaster drills? Tabletop drills, with toy cars and shoeboxes painted like houses are, obviously, insufficient. Shuffling chess pieces around the board and pretending that's equivalent to human lives in the parking lot just doesn't make sense. Nothing substitutes for what is called in disaster parlance, “getting cold and wet.” Full-scale scenarios with wet, “contaminated” patients, and front-line first receivers in bio-hazard gear will show hospital staff if they can properly cope with an influx of extra patients who need to be decontaminated. And a real disaster is not the time to discover that someone cannot function in the equipment provided. The best way to learn is by combining the familiar (the environment of the facility) with the unfamiliar (a disaster scenario of some type).

Question #2: Who's grading the drills? If your local hospital is holding drills, who's grading them?
A hospital grading its own performance is like asking a 10-year-old to grade his own final exam. Of course they'll give themselves good marks, because they aren't qualified to assess their own performance. In many cases, they might not even feel they're “cheating” by giving themselves unmerited high marks, but most hospital administrators and CEOs don't understand the standards or the evaluative procedure so they can't objectively measure outcomes. Determining who grades drills is critically important. Even though they'll be paid by the hospital, independent experts will offer a realistic, less biased assessment and will be capable of comparing the hospital to other similar facilities. An independent evaluator will be able to offer real recommendations to improve.

Question #3: Does the ER door lock? And can people get past it without any difficulty?
An episode of the television show ER pointed out this danger in the show's first minute and a half. Following a very realistic disaster scenario—a ruptured tank at a chemical plant—three victims arrived in the ER completely soaked and non-decontaminated. And because the ER doors didn't lock, they were able to walk straight in from the street, covered in a chemical so toxic that it ate through the floor laminate after the doctors stripped the victims of their clothes. A physician collapsed as the critically ill patients were hustled onto gurneys. Many emergency rooms have equally easy access, so the ER and every person in it can easily be contaminated. If the decontamination and first responder teams are in the ER at the time a contaminated individual or group wanders in, in effect the whole hospital is rendered useless and no longer has any ability to respond.

Question #4: Who is being trained?
Many hospitals make the mistake of training only those in the emergency room for disaster response. And if their ER becomes contaminated, a disaster quickly turns into a catastrophe. What's the difference? In a disaster, needs exceed resources. Trained providers have the people and the ability to respond, but run out of needed resources. In a catastrophe, needs exceed the ability to respond, and if you run out of trained responders, it doesn't matter how much “stuff” you have. So trained people must be spread throughout the hospital: front desk, custodial staff, administration, and every other department. In the event that one team is lost, another team can quickly fill in.

Question #5: What decontamination facilities are available?
In studies of every disaster, 80% of the victims arrive at the hospital by some means other than an ambulance, which means they show up contaminated or potentially contaminated. Is your local hospital set up with the equipment to offer decontamination? The days of a single small shower inside the ER are gone forever. Some hospitals have put in permanent showers while others store equipment that can be set up in 15 minutes in trailers. Many hospitals have moved to collapsible shower tents with a middle aisle for gurneys, for those people who cannot move themselves. These offer a modicum of privacy for those who enter the shower on one side in their contaminated clothes, and exit the other side in scrubs. And the majority still use a garden hose and nozzle. Or they may rely on their local fire department and hazmat team; this can be problematic, though, since those first responders will head to the site of the disaster, not to the hospital to spray down patients.

What can you do?
These five questions are tough ones that a lot of hospital administrators don't want to answer because they know they will get failing marks. But when people in their own community ask, “Where do we stand?” they can be compelled to answer and to fill in the gaps in their disaster preparedness. Therefore:

• Every time you go to the hospital for something as simple as a blood test, you'll get a satisfaction survey. At the bottom is a space to make a comment, so ask these questions every time you get such a survey.

• If your community's media haven't asked these questions of local healthcare administrators, then the public should be telling them to. Make phone calls to reporters at local papers and radio and television stations.

• Attend county commission and city government meetings on disaster planning and ask these questions. Almost every community now has at least one a year, if only to keep the Homeland Security dollars flowing.

• Every city, county, and state level of government has a website where you can ask these questions, as does every hospital. When you find the space where you're asked what they can do to make things better for the community, this is the answer.

Ready or Not…Here We Come
Fortunately, Hurricane Katrina-sized disasters and pandemic flus don't happen every year. But the sad truth is that, sooner rather than later, there will be another New Orleans, another Charity Hospital, and another total system failure if local communities don't take care of themselves.

Most hospitals now are private businesses, completely driven by public perception, and the opinion of the loudest voices wins. So one person speaking out can make a difference, and a group of people calling out can make a huge difference. If a hospital consultant makes a recommendation, a CEO is likely to say, “Sure, but you're not the one paying for it.” But if 50 or 100 or 1,000 hospital customers make the statement, that CEO will listen or will risk not being CEO anymore. When informed citizens in every county, every parish, and every city ask “Are we ready?” first receivers will be compelled to do what it takes to get the equipment, the people, and the training to keep everyone safe in the event of a disaster.