Appendix E: Resource Availability Systems

The proposed National System would improve the regulating function by improving access to resource availability information, in particular the availability of medical and transportation resources in an affected area (in order to help determine whether sufficient assets are in the area to treat and transport patients and evacuees) and outside the affected area (in order to help determine potential locations to where patients and evacuees could be transported). 

The table below describes systems currently in use—and with future development potential—that capture resource availability information.  They vary in any ways, including the frequency with which they are used (every day or only for declared emergencies) and the number of resources they track (ranging from one to dozens).  There is also an important distinction between inventories that list "baseline" resources (e.g. total hospital beds) vs. real-time available resources (e.g. hospital beds available today).  The sections following the table describe each current system in detail.  The purpose of this review is to highlight the primary examples of existing systems, rather than provide a comprehensive directory of all existing systems.

Resource System	Attributes	Control	Feasibility of Use/Development
Existing Baseline/inventory Systems
Hospital Bed Size	Annual Survey	American Hospital Association	In widespread use, straightforward to access
Nursing Home Bed Size	State Assessments, reported to CMS via OSCAR database	States and CMS	In use by CMS and researchers, accessible but less straightforward
Home Health Agency Size	State Assessments, reported to CMS via QIES. HHA capacity is more elastic and can expand more quickly than facility-based care.	States and CMS.	In use by CMS and researchers, accessible but less straightforward.
Homeless Shelter Capacity	State Assessments, reported to HUD	States and HUD	Accessible but not straightforward
Disaster Shelter Capacity	Information comes from every potential Red Cross disaster shelter	National Disaster Shelter System	Under construction; will be straightforward to use
Prisons & Jails	Cell/bunk space	Jurisdiction level (county, State, Federal Bureau of Prisons) but little sharing among jurisdictions
Transportation	Varies widely	Municipalities, private firms, airlines, etc.	Unexplored
Mixed-Asset Resource Inventories	Several designed, few in use	Rarely deployed	Might be deployed by more communities in the future
Existing Real-Time Resource Availability Systems
Numerous Hospital Bed Availability Systems	Some require new/frequent data entry, others pull data from other systems.	Local, county, region (each system has different potentials)	HAvBED explored pulling data from numerous/diverse local systems; it has not yet been implemented beyond a small test
Jail and Prison Availability Systems	Each jurisdiction knows how many cells/bunks are empty.	Jurisdiction level; not aggregated into an automated real-time database nationwide.
Mixed Asset Availability Systems	Various tools exist; some more widely deployed than others	Local, county, region (each system has different potentials)

CMS = Centers for Medicare and Medicaid Services; HAvBED = Hospital Available Beds for Emergencies and Disasters; HHA = home health agency; HUD = Department of Housing and Urban Development; OSCAR = Online Survey, Certification, and Reporting System; QIES = Quality Improvement Evaluation System.

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Hospital Assets

Hospital Baseline Resource Inventories

The American Hospital Association (AHA) conducts an annual survey to identify the number, size, and attributes of all U.S. hospitals, including psychiatric, children's, long term care, rehabilitation and general acute care  hospitals.  This survey is the standard widely-used data source for information about U.S. hospital capacity.  With the cooperation of State and Metropolitan Hospital Associations, the AHA achieves a very high response rate and the database contains information on 6,000+ hospitals and health care systems, including more than 700 data fields covering Organizational Structure, Personnel, Hospital Facilities and Services, and Financial Performance.  As hospital addresses are included, hospital capacity can be identified at the national, State, county and city levels.   AHA data could be used to pre-populate a database with a baseline inventory of capacity for every hospital in the country.  Bed counts change little from one year to the next, although hospitals do change their bed arrangements, open or close wings, etc.  Data on each hospital include:

• Total staffed and licensed beds.
• Medical/surgery beds.
• Pediatric beds.
• Intensive Care Unit (ICU) and Pediatric Intensive Care Unit (PICU) beds.
• Burn beds.
• Psychiatric beds.
• Rehabilitation beds.
• Skilled nursing beds.

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Hospital Real-time Availability Systems

A common resource availability system is one that displays the diversion status (i.e., is the hospital emergency department accepting new patients) of all hospitals in a region.  Many major urban areas have such a system.  Participating hospitals enter key data (e.g., whether they are accepting new patients or the number of beds available) on a Web page.  This helps emergency responders know where they can take patients, and it helps hospitals avoid having patients brought to them that they cannot accommodate.  These systems only inform responders that a hospital is unable to take additional patients; other systems have been developed that report on the availability of beds available in a hospital that still has space.

These systems include local "every day" bed availability systems  A widely used non-commercial application is ReddiNet (Rapid Emergency Digital Data Information Network).⁷⁶  Originally built in the 1980s for use in Los Angeles, ReddiNet has been modernized by the Hospital Association of Southern California, and is used 17 California counties.  ReddiNet  tracks hospital diversion status and resource availability, as well as alert and incident management functions. 

There are also local "activated" bed availability systems.  With activated systems, an alert is issued to hospitals and other participating organizations, that are asked to enter resource availability information into a Web site.  The resources asked for depend on the nature of the emergency.   As with the "every day" systems described above, the activated systems are intended to improve communication among hospitals, dispatch centers, emergency responders, and public health officials.  Web-based systems have replaced earlier "fax alert" and voice communication systems.  The extent to which these systems have been implemented across the country is not known, although there are state-wide implementations of systems in New York (the HERDS system); Maryland, Pennsylvania, and Delaware (the FRED system); and Washington, Oregon, and South Carolina (Harborview Medical's system).  Another large activated resource availability system is the National Disaster Medical System (NDMS).  When NDMS is activated, the 1,656 participating hospitals report to Federal Coordinating Centers (FCCs) the current number of available beds and the maximum number that could be made available in 24 and 48 hours.⁷⁷

Facilities Resource Emergency Database (FRED).  In response to 9/11, the State of Maryland wanted to implement a system that would improve communication among all hospitals, emergency responders, and public health agencies in the State.  Officials considered purchasing a commercial resource availability system but decided to develop their own.  Subsequently, the Maryland Institute for Emergency Medical Services Systems (MIEMSS) developed the Facilities Resource Emergency Database (FRED) system.  MIEMSS has also provided FRED to Pennsylvania and Delaware, where FRED is used statewide.  FRED has about 400 participating organizations across Maryland, including hospitals, dispatch centers, and, most recently, nursing homes, which were added to the system in the aftermath of Katrina.  Staff at these organizations have Web browsers directed to the FRED alert page.  Depending on the nature of the alert, organizations may be asked to provide resource availability information.  For example, an alert could be issued for all dispatch centers to enter the number of available ALS units. MIEMSS staff  used national standards in developing resource lists, including those used in the National Incident Management System (NIMS)⁷⁸ and the Strategic National Stockpile.⁷⁹

HERDS.  New York State's Health Emergency Response Data System (HERDS) is another example of an "activated" resource tracking system.  The New York  State  Department of Health developed this system to report resource needs and, as noted in the previous section, for entering patient names so that the public can determine where mass casualty incident victims have been transported.  HERDS staff participated in the HAvBED project, and developed an interface to report HERDS bed availability data to HAvBED.  With HERDS, hospitals can report availability (or urgent needs) for the a number of different resources, including beds, medical equipment, personnel, antibiotics, antidotes, blood, medical supplies, and pharmaceuticals. 

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National Hospital Availability Systems (HAvBED)

AHRQ funded Denver Health to develop the National Hospital Available Beds for Emergencies and Disasters (HAvBED) System.  The goal of this project was to "develop, implement and evaluate a real-time electronic hospital bed tracking/monitoring system that will serve as a demonstration management tool to assist in a system/region's ability to care for a surge of patients in the event of a mass casualty incident."⁸⁰  HAvBED could in theory be activated within a county, State, region or even nationally, during an Incident of National Significance.

The HAvBED team focused on acquiring bed availability data from existing systems, rather than replacing existing systems.  HAvBED assumes that local communities will continue to purchase and use systems that meet their own needs and that HAvBED should acquire information from these systems rather than requiring hospital staff to "double enter" bed availability information. 

HAvBED included development of data standards for defining and communicating bed availability.  Through a collaborative process involving many stakeholders, the project used the bed definitions in the National Disaster Medical System (NDMS) and added a 24-hour and 72-hour availability to each of the six bed types.  HAvBED also includes Emergency Department status (open, closed, or N/A), mass contamination facility availability (available or not available), and number of available ventilators. These data elements and the protocol for exchanging these data are now part of the Emergency Data Exchange Language (EDXL), which is part of the U.S. Department of Homeland Security's Disaster Management eGov Initiative.⁸¹

HAvBED underwent a 1-month test.  Three project partners provided data electronically, using XML: the Washington Hospital Capacity System, EMSystem, and HERDS.  During the test period, when hospital staff and the partner systems were feeding data to HAvBED, bed availability data were provided once a day.  The HAvBED report acknowledges "In day-to-day patient transports, bed availability is a second-by-second issue.  Having data entered once a day is not timely enough for this application."  Improving data timeliness without increasing the burden on data providers will be a challenge for HAvBED. Denver Health is currently enhancing HAvBED with funding from AHRQ. 

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Nursing Home Assets

Baseline Resource Inventories

Nursing homes are inspected by State agencies, and data about size, composition and other facility-level characteristics are collected.  The information collected regularly and reported to the Centers for Medicare and Medicaid Services' (CMS).  CMS's Online Survey, Certification, and Reporting (OSCAR) database contains information on facility-level characteristics.  OSCAR data results from onsite survey inspections of facilities by the State survey agencies.  These onsite facility evaluations occur at least once during a 15-month period.  State survey agencies are responsible for entering survey information into the OSCAR database at the State level and then transmit, in a standardized format, to CMS. Information on the nursing homes' characteristics are prepared by each nursing home at the beginning of the regular State inspection and reviewed by the nursing home inspectors.   The OSCAR database holds the nursing home characteristics and health deficiencies issued during the three most recent State inspections and recent complaint investigations.

Information collected, entered into the OSCAR database and transmitted to CMS includes facility characteristics (such as bed size, ownership type), staff information (employee and agency), and aggregate health status resident information and deficiency information.

CMS also has a public Web site, Nursing Home Compare (http://www.medicare.gov/NHCompare/Include/DataSection/Questions/SearchCriteriaNEW.asp), which has information on all Medicare/Medicaid certified nursing homes.  Searches can show the nursing homes in a State, county, or distance from a Zip code.  Information on each nursing home includes name, address, total number of certified beds, type of ownership, whether the facility is located in a hospital, and if it is owned by a multi-home organization.  Data from OSCAR provides the facility characteristic information and data from Minimum Data Set (MDS) provides facility-level quality measures.  There may be a fairly long lag time before the information from these two databases is updated on the Nursing Home Compare Web Site.

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Real-time Availability Systems

Nursing homes are required to assess their patients within 5 days of intake and report data to State agencies, who in turn report it to CMS of the Department of Health and Human Services (HHS).  These data are updated every 15-30 days.  This system could be used to estimate the number of available beds on an "average" day, but the lags and multiple steps in acquiring data would probably make this an unacceptably inaccurate source for real-time availability data.

The "activated" hospital bed availability called FRED (discussed above) has been adapted to include nursing homes.  We are unaware of other real-time availability systems for nursing home beds, and to our knowledge none of the systems described above for hospitals have incorporated such data for nursing homes (although they could potentially do so). 

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Home Health

Baseline Resource Inventories

As with nursing homes, State agencies certify home health agencies regularly, and report information about each HHA to CMS. At the national level, the Quality Improvement Evaluation System (QIES) includes all aspects of data collection and reporting on home health agencies.  The QIES includes HHA-level characteristics collected by the State survey agencies such as agency name, address, telephone number, services offered and type of ownership.  Each State survey agency is responsible for entering and updating the information into the QIES database.  The QIES also includes all OASIS assessment information that is submitted by the HHAs to their State survey agency.

CMS also has a public Web site, Home Health Compare (http://www.medicare.gov/HHCompare/Home.asp), which has information on all Medicare certified nursing homes.  A search of agencies provides the name, address, services available, and home health quality measures of agencies in a specified State, county or zip code.  The system does not have information on the number of patients served by each HHA.

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Real-time Availability Systems

There are no real-time availability systems for home health, and no mechanism to determine how many additional home health patients could be accommodated in a particular geographic region.  Home health care is somewhat elastic as it involves hiring more nurses, not building more "brick and mortar" infrastructure, so there is no licensed size limitation for an HHA and no finite capacity. 

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Shelter Assets

Baseline Shelter Resource Inventories

Local Homeless Shelter Inventories.  Continuums of Care use electronic systems to coordinate/integrate services for their clients.  They also report data about the services provided (number of clients, number of nights, etc.) to State agencies and then to HUD.  The capacity (in beds, rooms, apartments) of each shelter changes little from year to year, and these data are maintained by States and by HUD in a readily accessible database.  The beds are grouped by Emergency Shelter, Transitional Housing, or Permanent Supportive Housing.  The bed information is broken out by family units/family beds/individual bed, seasonal beds and overflow. They also have codes for various subpopulation and special needs served by the program, such as "domestic violence" or HIV or simply "male" or "female" if its a single-sex facility.

National Disaster Shelter Inventories.  The National (disaster) Shelter System is contains records from over 40,000 shelters include their capacity (how many people can take shelter in the facility) and several important functions like food preparation, back-up-generators, and heat.  In an emergency, the system can also show remaining available capacity, so managers can know when the shelter is "full".  (Note that the Coordinated Assistance Network [CAN] is the companion shelteree tracking system that records information about each person entering a disaster shelter.)

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Real-time Shelter Availability Systems

Local Homeless Shelter Availability Systems.  Most Continuums of Care that receive Federal funding use electronic systems that  report not only on services provided, but also on service availability.  Many of these systems also function as "reservation" systems so that social service agencies can locate a bed (or other services) for a homeless person.  Each of these systems operations locally and data are not reported on a real time basis.  There are a number of information technology (IT) vendors in this market, Systems like this generate reports on available services, including homeless shelter beds. Each of these systems is operated locally and data are not reported on a real time basis. 

An alternative approach would be to activate an emergency availability system—rather than using one that was created for everyday management of shelter client needs.  The Boston implementation of Web EOC has a bulletin board where individual shelters can enter the following information:

• Status—open or closed.
• Location.
• Date/time of last update.
• "Feeding space", including the number used and the number open each day.

"Sleeping space", including the number used and the number open each day.

National Disaster Shelter Availability Systems.  Ultimately, the American Red Cross's (ARC) National Shelter System will provide the ability to report bed availability at each activated shelter, so managers and disaster coordinators will know when a shelter is "full." This capability, however, does not currently exist, as the ARC has focused first on obtaining bed capacity data. 

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Transportation Assets

Baseline Transportation Resource Inventories

Local Transportation Inventories.  Most jurisdictions have information about the number of ambulances, medivac helicopters, buses, etc. in local private fleets, as well as in fire departments and other public/municipal fleets. Emergency Managers may have up-to-date—but probably not universal—lists from such sources at the local level, or can quickly assemble lists with a series of phone calls. This information is not, however, in an accessible database that can be linked to a national system.

Port authorities and public transportation systems similarly have information about the number of trains, subways, buses and other vehicles in the public domain, and can quickly share this with emergency managers.  Again, this information may not be in an accessible database that could link to a national system.

Regional trauma coordination includes deployment of medical evacuation "air ambulances"; the number of appropriately equipped planes and helicopters (and pilots) is known within each trauma region.  Depending on the State, this information may also be aggregated at the State level.

National Transportation Inventories.  For transportation assets, any transit agency that receives Federal funds must submit annual reports to the U.S. Department of Transportation's Bureau of Transportation Statistics (BTS).  Thus, the BTS has baseline or inventory data from transit agencies. 

The Department of Defense has a full baseline inventory of its transportation assets (and knows real-time availability as well).  The Department of Transportation knows its owned assets, and contracts with many vendors whose transportation assets are also known. Amtrak has a full and reasonably up-to-date inventory of its rail assets.  Airlines (and perhaps the FDA) know the number of functional planes in their fleets. 

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Real-time Transportation Availability Systems

Any public or private organization that manages a sizable fleet of vehicles will have computer systems that maintain status information (e.g., in service/out of service) on their vehicles.  Such organizations include those that operate buses (public transit agencies, school districts, and private contractors), taxis and ambulances (public agencies and private contractors), airplanes (commercial, private, and military), boats (public and private contractors), helicopters (local rescue and law enforcement agencies, military, privately owned), and trains (subway, local commuter rail, and AMTRAK). 

These computer systems are especially important for ambulances, because their availability status changes frequently and because a fast response is critical.  Computer-aided dispatch (CAD) systems for fire and emergency medical service (EMS) units have existed for over 25 years and dozens of vendors sell these systems.  Dispatchers at 911 centers answer emergency calls for service, enter details about the call (e.g., date, time, type of emergency) into the CAD system, and then assign one or more response units (e.g., an ALS or BLS ambulance) to the call.  When units have delivered their patient to the hospital, they radio the 911 center and the unit's status is changed to "available."  To carry out these functions, CAD systems keep track of which response units are assigned to calls and which are available for dispatch.  Some CAD systems are city-based; they track, for example, the availability status of all ALS and BLS ambulances in the city.  Others are county-based.  Some are operated by private ambulance companies whose response units provide services to several communities.   As with the patient tracking software applications, CAD systems are independently developed in the absence of any data standards. 

CAD systems have built-in rules (which dispatchers can overwrite) for how many and what type of response units should be dispatched to a particular type of call.  CAD systems also typically recommend specific units for dispatch, based on the unit's last known location and the incident location.  These rules and recommendations are for common types of incidents—fires, car accidents—and do not cover circumstances like evacuating an entire hospital, which would quickly exhaust all the response units.  In the event of a major incident, commanders would seek additional transportation assets from such organizations as public transit companies, the National Guard, the military, or private organizations with large numbers of vehicles, such as private bus, package delivery, or interstate freight companies.  Crisis management information systems would also be activated to help manage these incidents. 

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76. http://www.reddinet.com/index.html
77. As reported in the HAvBED final report, National Hospital Available Beds for Emergencies and Disasters (HAvBED) System: Final Report. AHRQ Publication No. 05-0103, December 2005. Agency for Healthcare Research and Quality, Rockville, MD.
78. http://www.nimsonline.com/resource_typing_system/index.htm
79. http://www.bt.cdc.gov/stockpile/
80. National Hospital Available Beds for Emergencies and Disasters (HAvBED) System: Final Report. AHRQ Publication No. 05-0103, December 2005. Agency for Healthcare Research and Quality, Rockville, MD. Available at https://www.ahrq.gov/research/havbed/.
81. http://www.whitehouse.gov/omb/egov/

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