Emergency departments are critical to the nation's response to disasters. History and recent events show the essential need for them to be prepared to respond. For example, the anthrax attacks in 2001, show that most victims usually arrive on foot or by personal vehicles and go to the nearest emergency departments within the first few hours of a disaster. The closest emergency department usually receives the greatest number of patients, while other hospitals in the area receive few, if any, disaster victims. In a flu pandemic, hospital emergency departments everywhere are likely to be overwhelmed with patients seeking treatment for flu-like symptoms.

Emergency physicians and nurses are first responders to disasters, including biological terrorist attacks and flu pandemics. Many have disaster medical experience and serve on teams that respond to disasters, such as Hurricane Katrina, and many serve as directors of hospital planning committees and provide medical direction to emergency medical services systems. In addition, emergency physicians play a crucial role in disaster planning, because emergency departments must coordinate among EMS, the community, and the hospital.

Patients will likely head to emergency departments when their symptoms become severe, and emergency physicians will likely be first to identify the rare symptoms caused by a biological agent or an infectious disease. These medical specialists also are key to the nation having an effective syndromic surveillance system, which would use Web-based technology to link regional health care system. The system would be used by medical professionals to report health-related data that may signal a possible infectious disease outbreak and help emergency medical personnel in the region to quickly identify and isolate infectious patients.

Most emergency departments struggle to meet the demands for day-to-day emergencies, let alone respond to disasters involving mass casualties. As we saw during Hurricane Katrina, it takes several days to open surge hospitals, and during that time, people can die.

In a disaster, the demand for health care could quickly outstrip the ability of hospitals to respond. Hospitals need the capacity and staff to treat large numbers of severely ill patients and limit the spread of infectious disease. They would need adequate equipment and supplies, including medications, personal protective equipment, quarantine and isolation facilities (e.g., negative pressure rooms), and air handling and filtration equipment.

However, according to a Government Accountability Office (GAO 2003) report, "Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism Response," a surge in emergency patients would overwhelm emergency departments in urban areas, many of which are already operating at or above capacity. In a questionnaire published in the American Journal of Public Health in May 2001, fewer than 20 percent of respondent hospitals had plans for biological or chemical weapons incidents, and only 12 percent had one or more self-contained, breathing apparatuses.

After the events of September 11, 2001, many hospitals and communities focused on disaster preparedness plans and conducted disaster response drills. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandated that all accredited hospitals in the United States have written disaster plans. However, having a plan does not equal preparedness. Unfortunately, the mere existence of a plan may create a false sense of security. According to experts, very few hospitals have emphasized the importance of integrated plans, and very few hospital disaster planners have actual experience.

Hospitals do not function in isolation; therefore, it is essential for out-of-hospital and hospital disaster plans to be integrated into community disaster plans. By working together, government authorities, community leaders, EMS, law enforcement, and hospital disaster planners can develop an effective approach to disasters and mass casualty events.

A recent survey by the Centers for Disease Control and Prevention said less than half of responding hospitals (46.1 percent) reported written memoranda of understanding with other hospitals in their communities to accept inpatients during a declared disaster (Sept. 27, 2005; No. 364). About.three-quarters said they were integrated into their community-wide disaster plans.

Although the U.S. government has developed a Domestic Preparedness Program to aid local emergency response agencies, there is clearly a gap between federal efforts and the current state of preparedness at the level of individual hospitals. Federal planners must therefore confront these deficiencies in local preparedness, according to emergency medicine experts.

Training must be consistent across the United States and be tailored to the roles of medical providers. It must be delivered through standard methods of training and certification. An ACEP task force identified the core content of a medical training program to prepare emergency physicians, nurses, and EMTs for a terrorist attack under a grant from the U.S. Department of Health and Human Services. The program is part of an ongoing federal effort to prevent and respond to terrorism in the United States. However, despite ACEP's advocacy efforts, the government has still not provided additional funding to implement the disaster training program.

In February 2006, ACEP proposed the following 10-Point Plan to Congress to increase capacity and alleviate overcrowding in the nation's emergency departments:

1. We must increase the surge capacity of our nation's emergency departments by ending the practice of "boarding" admitted patients in emergency departments because no inpatient beds are available. This will require changing the way hospitals are funded to allow for inpatient and intensive-care unit surge capacity to manage this burden.
2. We must implement protocols to collect and monitor real-time data for syndromic surveillance, hospital inpatient and emergency department capacities and ambulance diversion status. Collection of this data is vital to developing appropriate protocols.
3. Homeland Security agencies on the federal, state, and local levels need to understand that hospitals and emergency departments are part of the community's critical infrastructure. We cannot have response and recovery in a disaster without fully functioning, protected, and connected health resources.
4. We must require hospitals and communities that are severely affected by a natural or man-made disaster, or even a severe influenza outbreak, to postpone elective admissions until the crisis has abated. We must develop a way to compensate those facilities for their loss of revenue.
5. Command and control of disaster medical response must be more coordinated across federal, state and local agencies and departments.
6. We must establish a committee of stakeholders and disaster medicine experts from the public- and private-sectors and academic institutions to develop and/or refine national medical preparedness priorities and standards. We must change the national preparedness culture to one which is consensus-driven and evidence-based.
7. We must provide federal and state funding to compensate hospitals and emergency departments for the unreimbursed cost of meeting their critical public health and safety-net roles to ensure these emergency departments remain open and available to provide care in their communities.
8. We must establish a sustainable funding mechanism for disaster preparedness for hospitals, emergency departments and emergency management that is tied to national benchmarks and deliverables.
9. To ensure emergency physicians and nurses play a primary role in disaster planning and are considered in any national allocation of resources and protective measures, Congress should continue to include them in any definitions regarding first responders to disasters, acts of terrorism and epidemics.
10. Congress should pass H.R. 3875, the "Access to Emergency Medical Services Act," which provides incentives to hospitals to reduce overcrowding and provides reimbursement and liability protection for EMTALA-related care.