The National Disaster Medical System and military combat readiness: A scoping review

The National Disaster Medical System (NDMS) was designed to provide critical health care after natural disasters or a major overseas war. Created in the 1980s. Never fully tested. Will it actually work? #NDMS #DefinitiveCare #Disaster #HospitalPreparedness

ABSTRACT

A scoping review was conducted to describe the history of the National Disaster Medical System (NDMS) in the context of US military medical preparedness for a large-scale overseas military conflict. National Disaster Medical System civilian hospitals would serve as backups to military treatment facilities if both US Department of Defense and US Department of Veterans Affairs hospitals reached capacity during such a conflict. Systematic searches were used to identify published works discussing the NDMS in the scientific and gray literature. Results were limited to publicly available unclassified English language works from 1978 to January 2022; no other restrictions were placed on the types of published works. Full-text reviews were conducted on identified works (except student papers and dissertations) to determine the extent to which they addressed NDMS definitive care. Data charting was performed on a final set of papers to assess how these works addressed NDMS definitive care. The search identified 54 works published between 1984 and 2022. More than half of the publications were simple descriptions of the NDMS (n = 30 [56%]), and most were published in academic or professional journals (n = 38 [70%]). Only nine constituted original research. There were recurrent criticisms of and recommendations for improving the definitive care component of the NDMS. The lack of published literature on NDMS definitive care supports the assertion that the present-day NDMS may lack the capacity and military-civilian interoperability necessary to manage the casualties resulting from a large-scale overseas military conflict.

In December 1981, President Reagan established the Emergency Mobilization Preparedness Board (EMPB) to develop “a credible and effective capability to… support the [United States] armed forces while meeting the needs of the national economy and other civil emergency preparedness requirements.”^1(p2) The president tasked the EMPB with developing national policy and a national action plan for improving “emergency mobilization preparedness” that “reflect an integration of military and civilian objectives and capabilities.”^1(p2) Consequently, the EMPB established a working group devoted to health preparedness with representation from all federal agencies concerned with health services.² In 1984,^2,3 this working group announced its plans to develop the National Disaster Medical System (NDMS), with an original primary purpose “to provide medical evacuation and definitive care in the US for military casualties returning from an overseas war[,]” and a secondary mission “to supplement state and local medical resources during disasters and emergencies.”^4(p320)

Today, a conflict between the US and a near-peer adversary would result in an unprecedented number of combat casualties returning to the United States for medical care. However, the NDMS’s current ability to provide the scale and scope of definitive medical care necessary to meet these challenges is unknown: the NDMS's definitive care component has never been used for a large-scale overseas combat casualty scenario, and the NDMS's mission over the years has focused on the use of deployable disaster medical assistance teams (DMATs). To address this potential national security threat, Congress authorized the US Secretary of Defense to conduct the NDMS Pilot Program (“Pilot”) to improve the medical surge capability and capacity of the definitive care component of the NDMS in the National Defense Authorization Acts for Fiscal Years 2020 and 2021. Conducted over the course of 5 years in at least five NDMS regional network sites, the Pilot aims to improve the care of US combat casualties by assessing current NDMS federal-civilian interoperabilities, capabilities, and capacities and by developing substantive recommendations for strengthening the NDMS. To better inform the development of the Pilot, it is necessary to gain an understanding of the history of the NDMS as a whole and of concerns raised over time relating to the definitive care component in particular.

This report provides historical context for the Pilot by reviewing the NDMS’s original definitive care purpose with the guidance of a scoping review of the unclassified published literature on NDMS definitive care (http://links.lww.com/TA/C585). The objective of the scoping review is to describe the history of the NDMS in the context of military medical preparedness for a large-scale overseas military conflict. For purposes of this review, definitive care means medical care provided by an NDMS participating hospital for injuries or illnesses resulting directly from a specified public health emergency or for injuries, illnesses, and conditions requiring essential medical treatment or services to maintain health.⁵

MATERIALS AND METHODS

Literature Search Strategy

The search strategies for this scoping review were developed and conducted by a medical librarian and in accordance with established Enhancing the Quality and Transparency of Health Research guidelines.⁶ The librarian searched the biomedical literature databases Ovid MEDLINE, Embase, Web of Science, CINAHL, PsycINFO, and Scopus using a combination of keywords and search phrases to retrieve unclassified published works discussing the NDMS. Searches were conducted on September 15, 2021, and were limited to English language works from 1978 to the present. To capture additional publicly available English-language gray literature documents on the NDMS's definitive care component, the authors searched for both NDMS and “definitive care” on the Defense Technical Information Center website (discover.dtic.mil) and two websites maintained by the Office of the Assistant Secretary for Preparedness and Response in the US Department of Health and Human Services (HHS), phe.gov and asprtracie.hhs.gov. On January 19, 2022, Google Scholar was searched to identify additional unclassified English-language published works discussing both the NDMS and definitive care. There were no other restrictions on the types of publications searched on these databases and websites.

Search results were sorted and reviewed using the EndNote 20 desktop version (Clarivate, Philadelphia, PA) to remove duplicates and update references. The remaining records were then uploaded with their PDF files (if available) into Covidence (covidence.org), an online systematic review tool, for full-text review. Table 1 presents a summary of the search strategy for this scoping review. Title and abstract screenings were not conducted on Covidence because titles and abstracts were already screened as part of the search strategy described in Table 1.

TABLE 1.

Search Strategies for the NDMS Definitive Care History Scoping Review

Biomedical/Scientific Literature Database Searches (Title, Abstract, and Keyword Searches)	Date Searched	Search Results Kept: 289–170 Duplicates = 119 Results	Search Criteria
Ovid Medline	09/15/2021	56 Results	• (national-disaster-medical-system OR (ndms AND disaster*)).mp.
			• Limit 1 to English language
Embase	09/15/2021	78 Results	• (national-disaster-medical-system OR (ndms AND disaster*):ab,ti,kw) AND [english]/lim
CINAHL	09/15/2021	45 Results	• (national-disaster-medical-system OR (ndms AND disaster*))
			• S1 w/ Limiters - English Language
PsycINFO	09/15/2021	5 Results	• (national-disaster-medical-system OR (ndms AND disaster*))
			• S1 w/ Limiters - English Language
Web of Science	09/15/2021	30 Results	• TS = (national-disaster-medical-system OR (ndms AND disaster*))
			• AND LANGUAGE: (English)
Scopus	09/09/2021	212 Results − 137 non-NDMS records = 75 final results	• TITLE-ABS-KEY (((“national disaster medical system” OR “disaster medical assistance team*” OR “disaster mortuary operational response team*” OR “victim identification center” OR “national veterinary response team*” OR “federal coordinating center*” OR “trauma and critical care team*” OR “incident response coordination team*” OR “national medical response team*”) OR (ndms AND disaster*)))
			• AND (LIMIT-TO (LANGUAGE, “English”))
Other Gray Literature Searches (Full Text Searches)		Search Results Kept: 23 Results
DTIC.mil	09/16/2021	34 Results − 22 non-NDMS/irrelevant records = 12 final results	• (“national disaster medical system” OR ndms) AND “definitive care”
PHE.gov	9/16/2021	17 Results − 11 non-NDMS/irrelevant records = 6 final results	• National Disaster Medical System
			• “national disaster medical system” AND “definitive care”
ASPR TRACIE (aprtracie.hhs.gov)	9/16/2021	27 Results − 19 non-NDMS/irrelevant records − 3 inaccessible records = 5 final results	• National Disaster Medical System
Other Database Searches (Full Text Searches)		Search Results Kept: 65 Results
Google Scholar	01/19/2022	304 Results ➜ 277 actual results − 31 duplicates and/or foreign language − 181 non-NDMS/irrelevant records = 65 final results	• “national disaster medical system” AND “definitive care”
			• Limited to 1978 to present; unchecked ‘include citations’
Total search results kept for screening and full text review		207 Total Results

Full-Text Review Process

One reviewer performed initial full-text reviews. Works to be included for extraction required at least one substantive discussion of NDMS definitive care. The exclusion criteria were works focused on disaster medical care entirely outside of the United States; works containing only passing or nonsubstantive references to NDMS or definitive care; student papers, theses, or dissertations; and plans or planning documents for response operations. After completing the initial full-text review, all works designated for inclusion were reviewed a second time by either the lead or senior author before the final extraction of results.

Data Extraction: Charting the Results

The following information was extracted from the works included in this review:

the title, lead author, year of publication, type of content, and type of publication, and what aspects of NDMS definitive care are addressed in the work. One reviewer performed initial extractions using a customized electronic data extraction form created on Covidence, with a second reviewer performing a final consensus review of the extracted information.

RESULTS

After the searches and deduplication described in Table 1, 207 works were uploaded onto Covidence for full-text review, of which 54 substantively addressed NDMS definitive care (Table 2). The final flow diagram of the search results is presented in Figure 1.

TABLE 2.

Works Analyzed for the NDMS Definitive Care History Scoping Review

Abbreviated Reference	Publication Type	Audience	Nature of the Publication	Description
Mahoney LE et al. Planning a National Disaster Medical System. Mil Med. 1984;149 (12):657–60.	Journal article	Military medicine	Original descriptive	Earliest paper by the NDMS designers describing the intended purpose, design, and functions of the NDMS, including the NDMS's definitive care component and relationship to the overseas combat casualty scenario
Bisgard JC, Mullaly CF. The Civilian-Military Contingency Hospital System (CMCHS) in the USA. Prehosp Disaster Med. 1985;1 (1):35–8.	Journal article	Military medicine	Original descriptive	Description of the NDMS
Brandt EN et al. Designing a National Disaster Medical System. Public Health Rep. 1985;100 (5):455–61.	Journal article	Public health	Update of an original descriptive	Early paper by the NDMS designers describing the intended purpose, design, and functions of the NDMS, including the NDMS’s definitive care component and relationship to the overseas combat casualty scenario
Glasbrenner K. Disaster plan launches training, site selection. JAMA. 1985;253 (3):332–3.	Journal article	NDMS stakeholders	Original descriptive	Description of the NDMS
Mahoney LE. Medical preparedness for disasters. Ann Intern Med. 1986;104 (1):114–5.	Journal article	NDMS stakeholders	Original descriptive	Description of the NDMS
Mahoney LE, Brinley FJ. The National Disaster Medical System. Top Emerg Med. 1986;7 (4):75–85.	Journal article	Emergency medicine professionals	Derivative descriptive	Tailored material derived from earlier publications by the NDMS designers for dissemination to a particular audience/stakeholder group
Mahoney LE, Esch VH. The National Disaster Medical System. Emerg Med Serv. 1986;15 (5):13–9.	Professional/trade journal	Emergency medical services professionals	Derivative descriptive	Tailored material derived from earlier publications by the NDMS designers for dissemination to a particular audience/stakeholder group
Mahoney LE, Esch VH. The US National Disaster Medical System. Prehosp Disaster Med. 1986;2 (1–4):149–51.	Journal article	International disaster and emergency medicine professionals	Derivative descriptive	Tailored material derived from earlier publications by the NDMS designers for dissemination to a particular audience/stakeholder group
Moritsugu KP, Reutershan TP. The National Disaster Medical System: a concept in large-scale emergency medical care. Ann Emerg Med. 1986;15 (12):1496–8.	Journal article	Local communities	Derivative descriptive	Tailored material derived from earlier publications by the NDMS designers for dissemination to a particular audience/stakeholder group
Reutershan TP. National Disaster Medical System. Prehosp Disaster Med. 1986;2 (1–4):74–7.	Journal article	International disaster and emergency medicine professionals	Derivative descriptive	Tailored material derived from earlier publications by the NDMS designers for dissemination to a particular audience/stakeholder group
Mahoney LE, Reutershan TP. Catastrophic disasters and the design of disaster medical care systems. Ann Emerg Med. 1987;16 (9):1085–91.	Journal article	NDMS stakeholders	Original descriptive	Description of the NDMS with a focus on catastrophic earthquakes
Mahoney LE et al. Disaster medical assistance teams. Ann Emerg Med. 1987;16 (3):354–8.	Journal article	NDMS stakeholders	Original descriptive	Description of the NDMS with a focus on special response teams
Federal Register (Vol. 53, pp. 12994–95) (1988)	Legal/regulatory authority	General public	Derivative policy	Official US Government announcement of the creation of the medical manpower component within the HRSA in HHS as a part of the NDMS (including the definitive care/hospital beds component) “to meet essential civilian disaster needs and assist during national security emergencies”
Reese CA. The National Disaster Medical System. J Am Assoc Nurse Anesth. 1989;57 (6):493–9.	Journal article	Anesthesia professionals	Update of an original/derivative descriptive	Tailored and updated material derived from earlier publications by the NDMS designers for dissemination to a particular audience/stakeholder group
Wachtel TL et al. Developing a regional and national burn disaster response. J Burn Care Rehabil. 1989;10 (6):561–7.	Journal article	Burn care professionals	Original/update of an original descriptive	Original tailored analysis that includes updated material derived from earlier publications by the NDMS designers for dissemination to a particular audience/stakeholder group
Clark WD et al. The National (United States) Disaster Medical System: a survey and analysis. Prehosp Disaster Med. 1991;6 (1):35–9.	Journal article	International disaster and emergency medicine professionals	Original research	Survey of emergency medical directors of NDMS hospitals in North Carolina to assess views on the need for NDMS and the level of hospital preparedness; includes several items about military casualties of an overseas conflict
Pretto Jr. EA, Safar P. National medical response to mass disasters in the united states: are we prepared? JAMA. 1991;266 (9):1259–62.	Journal article	US medical professionals	Original editorial	Critique of NDMS at a stage when it was not yet fully implemented, with frequent comparisons between the needs of sudden domestic disasters vs. military contingencies
Glick J, Birnbaum ML. Perceived preparedness for a mass casualty disaster in the United States: a survey. Prehosp Disaster Med. 1998;13 (2–4):28–43.	Journal article	NDMS stakeholders	Original research	Survey of 88 federal, state, and local disaster health agencies that indicated significant concerns about the health care system's capacity to respond
Briggs S. Sustaining the response OCONUS. In: Alexander Y, Prior S, editors. Terrorism and Medical Responses: US Lessons and Policy Implications. Leiden: Brill Nijhoff; 2001. p. 79–86.	Book chapter	NDMS stakeholders	Original descriptive	Book chapter about US overseas response, including the NDMS's role in such responses
Knouss RF. National Disaster Medical System. Public Health Rep. 2001;116(Suppl 2):49–52.	Journal article	Public health	Update of an original descriptive	Detailed description of definitive care component and its state at the dawn of the 21st century (before 9/11)
Rosen JM et al. Cybercare NDMS: an improved strategy for biodefense using information technologies. Stud Health Technol Inform. 2003;97:95–114.	Journal article	NDMS stakeholders	Original editorial	Editorial arguing that the NDMS is insufficient in the face of biological threats and for the need to strengthen public health preparedness
Cancio LC, Pruitt Jr BA. Management of mass casualty burn disasters. Int. J. Disaster Med. 2004;2 (4):114–29.	Journal article	Burn care professionals	Original research	Review of prior mass burn incidents with recommendations to improve burn care for the NDMS
Lhowe DW, Briggs SM. Planning for mass civilian casualties overseas: IMSuRT—International Medical/Surgical Response Teams. Clin Orthop Relat Res. 2004;422 (422):109–13.	Journal article	International disaster and emergency professionals NDMS stakeholders	Original descriptive	Description of the development of a DHS International Medical-Surgical Response Team, based on NDMS experience
Lord EJ, Cieslak TJ. Joint Regional Exercise (“JREX”) 2000. Disaster Manag Response. 2004;2 (1):24–7.	Journal article	NDMS stakeholders	Original research	Original report about a multijurisdictional, multiagency exercise that examined the response capabilities of multiple agencies and institutions within the NDMS and identified critical interventions necessary to improve NDMS preparedness
Rosenthal MS et al. Disaster modeling: medication resources required for disaster team response. Prehosp Disaster Med. 2005;20 (5):309–15.	Journal article	Disaster and emergency medicine professionals	Original research	Original report about the development of a model to predict patient complaints and the medicine and supplies needed for the management of NDMS patients for mobile teams
Stopford BM. The National Disaster Medical System — America’s medical readiness force. Disaster Manag Response. 2005;3 (2):53–6.	Journal article	Emergency nursing and disaster management/response professionals	Derivative descriptive	Tailored material derived from earlier publications by the NDMS designers for dissemination to a particular audience/stakeholder group, with only a passing reference to the overseas combat casualty scenario
Franco C et al. Systemic collapse: medical care in the aftermath of Hurricane Katrina. Biosecur Bioterror. 2006;4 (2):135–46.	Journal article	Health security professionals and scholars NDMS stakeholders	Original research	Qualitative interviews of medical responders to Hurricane Katrina (2005) that identified: weaknesses in federal, state, and local disaster medical planning; poor NDMS preparedness; weak volunteer management; and inadequate medical record availability
Nelson HW, Arday D. Medical aspects of disaster preparedness and response: a system overview of civil and military resources and new potential. In: Greenstone J, Hershkowitz M, editors. State Defense Force Monograph Series. Winter 2006. Germantown, MD: State Defense Force Publication Center; 2006. p. 41–67.	Monograph	NDMS stakeholders	Original descriptive	Review of NDMS and other civilian and military medical resources for supporting disaster response manpower strategies.
Franco C et al. The National Disaster Medical System: past, present, and suggestions for the future. Biosecur Bioterror. 2007;5 (4):319–25.	Journal article	Health security professionals and scholars	Original descriptive	Original review of the history and structure of the NDMS definitive care component as of 2007, including its original relationship to the overseas combat casualty scenario
Sanford C et al. Medical treatment at Louis Armstrong New Orleans International Airport after Hurricane Katrina: the experience of disaster medical assistance teams WA-1 and OR-2. Travel Med Infect Dis. 2007;5 (4):230–5.	Journal article	NDMS stakeholders	Original descriptive	Description of the NDMS response to Hurricane Katrina (2005), with a focus on DMAT teams and evacuations
Sklar DP et al. Responding to disasters: academic medical centers' responsibilities and opportunities. Acad Med. 2007;82 (8):797–800.	Journal article	Emergency management scholars NDMS stakeholders	Original editorial	Editorial arguing for the role of academic medical centers in health care disaster response, including in the NDMS and DMATs
Toner E et al. A national disaster medical system for the 21st century. Biosecur Bioterror. 2007;5 (3):192–3.	Journal article	NDMS stakeholders	Original editorial	Recommendation for NDMS planning for catastrophic disasters
Christian MD et al. Definitive care for the critically ill during a disaster: current capabilities and limitations. From a Task Force for Mass Critical Care Summit Meeting, January 26–27, 2007, Chicago, IL. Chest. 2008;133 (5 Suppl):8S–17S.	Journal article	Disaster and emergency medicine professionals	Original editorial/review (not NDMS-focused)	Description of the limited capacity and preparedness of the US health care and critical care system for a catastrophic disaster
Koenig KL. National Disaster Medical Systems activation in a public health response—a tale of Hurricane Katrina. Prehosp Disaster Med. 2008;23(S2):s83-s6.	Journal article	NDMS stakeholders	Original editorial	Summary of a panel discussion of the NDMS response to Hurricane Katrina (2005)
National Biodefense Safety Board. Strategic Improvements to the National Disaster Medical System (NDMS): Report from the Disaster Medicine Working Group NDMS Assessment Panel. Washington, DC: National Biodefense Science Board; 2008.	Report	NDMS stakeholders	Original policy	Summary of recommendations to improve the NDMS, including definitive care capacity
Quinlisk P. National Biodefense Science Board NDMS Assessment Panel Recommendations Letter to US Secretary of Health and Human Services. October 6, 2008.	Letter	Federal government NDMS stakeholders	Original policy	Letter transmitting summary of 16 recommendations to improve the NDMS following Hurricane Katrina (2005) to the HHS Secretary
Salinsky E. Strong as the Weakest Link: Medical Response to a Catastrophic Event [Background Paper No. 65]. Washington, DC: National Health Policy Forum; 2008.	Monograph	DoD stakeholders	Original descriptive	Review of government strategies and activities to increase health care capacity, including the NDMS, SNS, and HPP
Mackenzie C et al. How will military/civilian coordination work for reception of mass casualties from overseas? Prehosp Disaster Med. 2009;24 (5):380–8.	Journal article	International disaster and emergency medicine professionals	Original research	Original report about tabletop and functional exercises to simulate activation of the NDMS during an overseas combat casualty scenario in Maryland/National Capital Region
Barbisch D et al. Surge Capacity. In: Koenig KL, Schultz CH, editors. Koenig and Schultz’s Disaster Medicine: Comprehensive Principles and Practices. Cambridge, UK: Cambridge University Press; 2009. p. 33–50.	Book chapter	NDMS stakeholders	Original descriptive	General discussion of health care surge capacity and response, including the NDMS
Margesson R, Taft-Morales M. Haiti Earthquake: Crisis and Response. Washington, DC: Congressional Research Service; 2010.	Federal report	NDMS stakeholders	Original policy	Congressional Research Service summary of the US Government's response to the 2010 Haiti earthquake, with recommendations to improve the NDMS
Marklund LA et al. Collaboration between civilian and military healthcare professionals: a better way for planning, preparing, and responding to all hazard domestic events. Prehosp Disaster Med. 2010;25 (5):399–412.	Journal article	NDMS stakeholders	Original editorial/review (not NDMS-focused)	Review summarizing the history and policy of disaster response collaboration between civilians and the military, with recommendations for increased shared medical training
Mason WL. The incomplete circle of the National Disaster Medical System: what Arkansas hospitals learned from Hurricane Gustav. Biosecur Bioterror. 2010;8 (2):183–91.	Journal article	Health security professionals and scholars NDMS stakeholders	Original research	Survey of 10 Louisiana hospitals that received NDMS patients after Hurricane Gustav (2008) that identified difficulties with repatriation, reimbursement, and extended lengths of stay
Landesman LY. Structure and organization of health management in disaster response. In: Landesman LY, editor. Public Health Management of Disasters: The Practice Guide. 3rd ed. Washington, DC: APHA Press; 2011. p. 37–85.	Book chapter	NDMS stakeholders	Original descriptive	Description of disaster health response with a discussion of the NDMS
Murray JS. National Disaster Medical System: providing disaster care of national significance. Am J Nurs. 2012;112 (2):58–63.	Journal article	Emergency nursing and disaster management/response professionals	Original descriptive	Description of the NDMS
Hanfling D. Role of Regional Healthcare Coalitions in Managing and Coordinating Disaster Response [White Paper]. National Response to an Improvised Nuclear Attack, National Academy of Science, Institute of Medicine; 2013; Washington, DC.	Monograph	Health security professionals and scholars	Original descriptive	Summary of health care surge capacity, including Health Care Coalitions and the NDMS
Institute of Medicine. Nationwide Response Issues After an Improvised Nuclear Device Attack. Washington, DC: The National Academies Press; 2014.	Book/report	Health security professionals and scholars	Original descriptive	NASEM report that summarized the US response to a nuclear event, including NDMS definitive care surge capacity
Horahan K, Hunt RC. The federal medical response to disasters. In: Cone D, Brice JH, Delbridge TR, Myers JB, editors. Emergency Medical Services: Clinical Practice and Systems Oversight. Vol. 2. Second ed. Hoboken, NJ: John Wiley & Sons; 2015. p. 278–82.	Book chapter	NDMS stakeholders	Original descriptive	Discussion of ESF8 roles and responsibilities, including the NDMS
U.S. Department of Defense. DOD Instruction 6010.22, “National Disaster Medical System (NDMS)”. 2016.	Federal policy document	DoD stakeholders	Original policy	Official DoD issuance on DoD’s role and NDMS’s role during a military health emergency (e.g., overseas conflict)
National Disaster Medical System. National Disaster Medical System Federal Coordinating Center Guide. Washington, DC: US Department of Health and Human Services; 2018.	Federal guide	NDMS stakeholders	Original policy	General overview of the overall structure/operation of FCCs and NDMS, including several references to their role during military health emergencies (e.g., overseas conflicts)
National Disaster Medical System. National Disaster Medical System Health Care Facility/Partner Memorandum of Agreement for Definitive Medical Care [Template].	Memorandum of agreement template	NDMS stakeholders	Original policy	Template for agreement signed by NDMS definitive care partners that addresses the NDMS’s purpose and explains the roles and responsibilities of NDMS definitive care partners, including during responses to military health emergencies such as an overseas combat casualty scenario
Vora NM e al. Challenges of service coordination for evacuees of Hurricane Maria through the National Disaster Medical System. J Emerg Manag. 2018;16 (3):203–6.	Journal article	NDMS Stakeholders	Original research	Review of NDMS care for Hurricane Maria (2017) dialysis evacuees that found limited capacity and capability of dialysis centers, resulting in the delayed return home of many dialysis evacuees
King B et al. Burn mass casualty and disaster. Med Res Arch. 2018;6 (9).	Journal article	NDMS and DoD stakeholders	Original descriptive	Discussion of the organization of mass casualty burn response, including the NDMS and DoD roles
Isakov AP et al. Disaster preparedness and management. In: Cone D, Brice JH, Delbridge TR, Myers JB, editors. Emergency Medical Services: Clinical Practice and Systems Oversight. Vol. 2. Third ed. Hoboken, NJ: John Wiley & Sons; 2021. p. 283–92.	Book chapter	NDMS stakeholders	Original descriptive	General description of disaster preparedness and response with a discussion of the role of the NDMS
Remick RN et al. COVID-19: opportunity to re-imagine our response to a national medical crisis. J Am Coll Surg. 2021;232 (5):793–6.	Journal article	NDMS and DoD stakeholders	Original editorial/review (not NDMS-focused)	Discussion of COVID-19’s impact on health care and the need for improved government-private sector collaboration

DHS, Department of Homeland Security; FCCs, Federal Coordinating Centers; HPP, Hospital Preparedness Program; HRSA, Health Resources and Services Administration; NASEM, The National Academies of Sciences, Engineering, and Medicine; SNS, Strategic National Stockpile.

Figure 1.

Flow diagram for the NDMS definitive care history scoping review (adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews⁶).

More than half of the publications were simple descriptions of the NDMS (n = 30 [56%]), and an additional 15% were editorials or non-NDMS-focused review articles (n = 8). The remainder was government policy or operational documents (n = 7 [13%]) or research related to NDMS (n = 9 [17%]). The vast majority were published in academic or professional journals (n = 38 [70%]). Six (11%) related to monographs published by organizations like the National Academies of Sciences, Engineering, and Medicine, five (9%) were book chapters, and the remaining five (9%) were federal government publications. Half of the descriptive papers (n = 15) were published in the first 5 years after the NDMS was established. There were only three publications during the 1990s, but there has been a small, regular output since 2001.

Summary History of the NDMS Definitive Care Component

The NDMS was built on the Civilian-Military Contingency Hospital System, which was established in 1980 as a cooperative venture using civilian hospital beds to care for military casualties exceeding the capacity of US Department of Defense (DoD) and Department of Veterans Affairs (VA) hospitals.² Although the Civilian-Military Contingency Hospital System had no deployable medical resources and was thus of limited utility in domestic (civilian) disasters, it generated great interest in emergency preparedness within the US health care community and provided a model for designing the NDMS definitive care component.^2,3

Originally, the NDMS was expected to provide care for up to 100,000 serious injuries requiring hospitalizations generated by a domestic disaster or a major overseas (primarily European) conventional military conflict through a coordinated program involving federal, state, local, and private-sector partners.^2,3 The NDMS's objectives were to:

1. provide medical assistance to a disaster area in the form of medical assistance teams and medical supplies and equipment;

2. evacuate patients who cannot be cared for in the affected area to designated locations elsewhere in the United States; and

3. provide definitive medical care in a national network of hospitals that have agreed to accept patients in the event of a national emergency.

With regard to the third (definitive care) component, the NDMS designers envisioned that “[l]icensed and accredited [civilian] hospitals of 100 or more beds [would] participate voluntarily in the [NDMS], if they agree[d] to participate in a specified training and exercise program and to accept NDMS patients in proportion to specialty service needs and their available bed capacity.”^2(p458)

The NDMS could be activated in three ways:

1. by the president through a major disaster or emergency declaration under the Disaster Relief Act of 1974;

2. by the secretary of HHS during a public health emergency under the Public Health Service Act; and

3. by the secretary of defense in the event of a national security (military) emergency.

Implementation of the NDMS was initially expected to unfold over 5 years, with most of the system to be developed during the first 3 years of that period.² The NDMS was formally activated for the first time in 1989 in response to Hurricane Hugo,⁷ although the NDMS was still only partially implemented as of 1991.⁸

The Present-Day NDMS (Post-2001)

The NDMS operated administratively within the federal Executive Branch until it was statutorily authorized under the Public Health Security and Bioterrorism Preparedness and Response Act of 2002 after the Fall 2001 terrorist attacks.⁹ Today, the NDMS partners with health care facilities around the United States “to ensure a network is in place to provide care for [US] citizens [and] military casualties requiring additional or complex care unavailable within an area impacted by a natural, man-made disaster, military health emergency, or other public health emergency.”¹⁰ Activation of the NDMS still occurs by the three mechanisms identified by the original NDMS designers.¹¹

US Department of Health and Human Services is the lead federal agency for NDMS definitive care during domestic disasters and emergencies through partnership with DoD, VA, and the US Department of Homeland Security (DHS). In this domestic scenario, NDMS operates through 65 DoD- and VA-operated Federal Coordinating Centers to manage medical evacuation from areas impacted by a disaster to designated reception facilities and distribution of patients to a network of 1,600+ civilian health care facilities for definitive care. These private-sector health care partners voluntarily agree to care for NDMS federal patients at a reimbursement rate of 110% of the current Medicare rate.¹² Federal Coordinating Centers are operated by DoD Medical Treatment Facilities or VA Medical Centers responsible for day-to-day coordination of planning and operations in one or more NDMS patient reception areas.^5,11

By contrast, during military health emergencies such as a large-scale overseas military conflict, DoD functions as the lead federal agency for NDMS. In this military scenario, the NDMS civilian health care partners serve as backups to military treatment facilities when both DoD and VA hospitals reach capacity.^5,11

Since its creation, the NDMS's mission has evolved from its primary focus on military casualties during an overseas conflict toward its secondary mission of civilian support in domestic disasters and emergencies.⁴ By 2006, the NDMS had become the federal government's primary medical response system for large regional and national disasters in the United States, primarily through the deployment of DMATs. The first full-scale operation involving the NDMS's patient movement capability occurred in the aftermath of Hurricane Katrina in 2005.^4,13 By contrast, the NDMS has never been used for its primary purpose of providing medical care to evacuated military casualties from an overseas conflict.

Summary of NDMS Definitive Care Specific Research

The authors identified only nine peer-reviewed research publications related to NDMS definitive care since 1982. Four used qualitative or quantitative surveys to identify significant issues related to NDMS preparedness, including a lack of awareness of NDMS roles,¹⁴ concerns about limited federal health response capacity,¹⁵ difficulty in discharging NDMS patients from private hospitals,¹⁶ and lack of coordinated health care response.¹³ Two studies were analyses of NDMS exercises that identified important operational issues related to civilian-military and civilian-federal coordination.^17,18 Two articles reviewed definitive care for burn¹⁹ and dialysis²⁰ patients, and another modeled the medical and pharmaceutical needs of potential NDMS patients.²¹

Discussions of NDMS Deficiencies

There were several editorials and monographs that discussed deficiencies of the NDMS during domestic disaster responses and recommended improvements. The impact of and flawed response to Hurricane Katrina in 2005 led to a widespread review of the NDMS. Looking to improve US health preparedness, Congress passed the Pandemic and All-Hazards Preparedness Act of 2006, which included requirements that HHS review the NDMS and evaluate national medical surge capacity in partnership with DHS, DoD, and VA. As part of this review process, HHS requested feedback from the National Biodefense Science Board, which established an NDMS Assessment Panel comprised of public- and private-sector subject matter experts.²² The Panel noted that the NDMS “does not represent an overall system to provide for the medical needs of patients at a time of national need” and made 12 recommendations that included improvements to the definitive care component.²²

Academics and policymakers also critiqued the NDMS. Soon after Katrina, Franco et al.¹³ identified critical shortcomings with health care system preparedness and response following the hurricane, labeling it a “systemic collapse.” In a follow-up article, Franco et al.⁴ made specific recommendations to improve the NDMS definitive care component, including increasing private health care system engagement in preparedness and response; using regional hospital networks to organize the NDMS system; and developing non-DoD patient transportation and tracking systems. Other publications further emphasized the need to strengthen national and regional government and private health care collaborations to increase health care response capacities.^23,24 Nevertheless, criticism of the NDMS's performance during domestic disasters continued in the following years. For example, Mason¹⁶ reported on the challenges NDMS-participating hospitals in Arkansas had with the repatriation and reimbursement for NDMS patient care after Hurricane Gustav in 2008.

Concerns and recommendations have also been made for improving NDMS preparedness and response for a large-scale military conflict. As mentioned previously, the NDMS has never been tested or used to any scale during an overseas military conflict. Furthermore, the NDMS has been exercised infrequently between military and civilian NDMS partners in many places. For example, in reporting on Maryland's first exercises between military and civilian NDMS partners in over two decades, Mackenzie et al.^18(p387) observed that “[s]ince the beginning of the NDMS, activation of patient reception in Maryland never has occurred, and since the only other exercises were in the 1980s… most of the exercise participants had no experience with NDMS response or in interacting with the military.” This history suggests that the present-day NDMS may lack the capacity and military-civilian interoperability necessary to manage the casualties resulting from a large-scale overseas military conflict.

DISCUSSION

Since its creation in 1984, the NDMS has drifted from its original mission to care for US military casualties from an overseas conflict toward an emphasis on the mobile medical (DMAT) response to domestic disasters. The definitive care component of the NDMS remains critical for US military preparedness but has never been used and only superficially exercised. Numerous authors, particularly after major disasters, have repeatedly raised concerns that the NDMS does not have the capacities and capabilities to respond to a catastrophic disaster or a large-scale conflict. Recommendations for increasing NDMS definitive care capabilities and capacities focus on either strengthening civilian-military coordination,^{17–19,25–29} civilian-federal coordination,^{13,15,16,22,27,29,30} or regional health care response coordinating bodies.^{17,23,27,31,32}

Given the critical nature of the NDMS for US security, it was surprising to find so few publications focused on the system in general and, more specifically, on its definitive care component. The majority of published works identified in this review provided a historical and operational description of the NDMS and examples of NDMS deployments in the aftermath of natural disasters. Editorial and policy papers critiquing and recommending improvements were the next most common group. Research was severely lacking: only nine NDMS definitive care research publications during the entire 38-year history of the NDMS were identified. This dearth of unclassified published literature on NDMS definitive care highlights the need for the NDMS Pilot Program, which will engage NDMS stakeholders over the next 5 years to address the potential national security ramifications of the NDMS’s limited medical surge capacity to care for US combat casualties returning from an overseas conflict.

National Disaster Medical System stakeholders already have identified opportunities for the Pilot to accomplish its objectives by building upon best practices from the US response to the 2020–2022 COVID-19 pandemic, which greatly stressed the US health care system and exposed the severe limitations in the domestic system's ability to care for repeated surges of infected patients.^33,34 Although the NDMS's definitive care and transportation components were not activated during the pandemic, the DMATs (along with National Guard and active duty health care personnel) were used to supplement civilian resources in a number of states. These COVID-related precedents may have critical relevance for preparing NDMS hospitals to respond to a future overseas combat casualty scenario.

Limitations

Several limitations in the conduct of this scoping review may have influenced the results. As a result of the use of title, abstract, and keyword searches instead of full-text searches to identify literature on biomedical and scientific databases, an unknown number of relevant works may have been missed. In addition, this review did not include various legislative, legal, and regulatory databases (e.g., LexisNexis, Westlaw) that may have uncovered relevant works from the academic and gray literature in law and policy. Furthermore, the selective use of a small number of databases to search the gray literature likely limited the overall output of relevant works from the gray literature that were identified in this review. Finally, the use of only one reviewer to conduct initial full-text reviews and data extractions renders the results of this review especially vulnerable to the reviewer's individual biases.

These limitations do not undermine the core finding of this report that there has been scant consideration of the overseas combat medical surge and military health emergency scenario in the publicly available unclassified published literature on NDMS definitive care since the earliest years of the NDMS. The authors acknowledge, however, that additional works relevant to this historical review may reside in the NDMS's nonpublic operating documents or in the classified literature about the NDMS.

CONCLUSION

The NDMS has a vital role in US preparedness for large-scale military conflicts and domestic disasters. Nevertheless, there are significant questions about its capabilities, particularly in the definitive care component responsible for medical care following a catastrophic disaster or conflict. Despite decades of repeated evaluations that have yielded recommendations for improving the NDMS, implementation of corrective actions has been limited. Recent critics have characterized the NDMS as “a Cold War relic: relevant, but outdated,”³⁵ (slide 8) and a subcomponent of the US health care system, which “is wholly unprepared for a wide range of 21st-century health threats.”^36(p1134) The lack of published literature supports the assertion that the present-day NDMS may lack the capacity and military-civilian interoperability necessary to manage the casualties resulting from a large-scale overseas military conflict. This scoping review provides historical context to inform the DoD-led NDMS Pilot Program currently underway to start addressing these extant issues in the NDMS.

Supplementary Material

jt-93-s136-s001.docx ^{(101.5KB, docx)}