A 2007 pandemic exercise in Maricopa County, Arizona, the 5th largest urban population in the United States, revealed major vulnerabilities in planning, response, resource utilization, and the decision-making process, which would be common to any large urban setting where multiple independent organizations exist and have not yet coordinated or shared their plans. Communication challenges are both prevalent and magnified in large urban settings. There must be tough, broad-based decision making by healthcare leadership with guidance and processes at every level to assure compliance to the primary goals of pandemic flu plans necessary to control the transmission rate of the disease. A unifying decision-making element such as a Health-related Emergency Operations Center is critical for the coordination, which serves all urban health systems. Education and training in pre-event protocols for triage management is crucial at every level where resources will be scant. This is especially true in admissions to intensive care units and priorities for ventilator use.
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