Over the past century, we have achieved great gains in medicine, public health, and health-care infrastructure, particularly in the areas of vaccines, antibiotics, sanitation, intensive care, and medical technology. Still, despite these developments, infectious diseases are not only spreading faster at an unprecedented rate around the globe, they appear to be emerging at a faster rate,^{Reference Smith, Goldberg and Rosenthal1} and are capable of spreading around our world in 36 h or less.^{Reference Knobler, Mahmoud and Lemon2} Large urban centers are particularly vulnerable to communicable disease events, and must have well-prepared response systems, including on the front-line level. In November 2018, the United States’ largest municipal health-care delivery system, New York City Health + Hospitals (NYC H+H), hosted a half-day executive-level pandemic response workshop, which sought to illustrate the complexity of preparing for, responding to and recovering from modern-day infectious diseases impacting urban environments. More than 100 health-care executives, senior advisors, emergency managers, academics, and government officials as well as local, state, national, and international public health community members attended the workshop. Attendees were subjected to a condensed, plausible pandemic influenza scenario and asked to simulate the high-level strategic decisions made by leaders by internal (eg, Chief Medical Officer, Chief Nursing Officer, and Legal Affairs) and external partners (eg, city, state, and federal public health and emergency management entities) across an integrated system of acute, post-acute, and ambulatory sites, challenging players to question their assumptions about managing the consequences of a highly pathogenic pandemic.

The event revealed, from a systems perspective, distant, isolated disease outbreaks would have little effect on day-to-day operations unless specific actions were recommended from public health agencies. However, as the hypothetical outbreak became more widespread, recurrent themes of needs became increasingly evident.

First, when dealing with large-scale outbreaks in urban areas, enhanced resources and tools need to be made immediately available to those on the ground. Local surveillance systems now hold the ability to incorporate real-time data from local, regional, and national databases into decision support tools, but these technologies are rendered inconsequential should resources not be allocated appropriately or in a timely fashion. In the United States, state and federal stockpiles of medical supplies exist can be rapidly distributed,^{Reference Redd and Frieden3} but a pandemic scenario is likely to complicate resource allocation on local and sub-national levels because of competing areas of similar need, limiting the allocation and deployment of these resources.

This bottleneck could be ameliorated through technology by decreasing our reliance on human estimation thresholds of when to galvanize action. During emergencies, decision-makers may be inundated with data and information leading to improvident action, or worse, inaction. Tools and technology that automate the presentation of data to decision-makers could help by triggering alerts and pushing messages indicating aberrancy to both decision-makers and front-line staff. Theoretically, this technological dashboard with decision support tools would improve outbreak response by leading to the earlier mobilization of resources. This technology also holds the potential to provide front -line staff with diagnostic tools, staffing resources, and supply chain management priorities in scalable, deployable fashions separate from current modeling by providing triggers and notifications in real time when preset warning thresholds are crossed.

Acknowledging ongoing events places a large burden on systems, and financial assistance is critical for public resources to sustain sufficient stockpiles and implement additional services related to outbreak response, the coordination of resources is also of the utmost importance. Technologies and tools for triggering for the request of resources at the local, state, and national levels should be developed and implemented, as should sequences for quantifying the severity and need for requisition, accessing, and distributing resources during an outbreak response.

Exercise participants advocated for the establishment of a multidisciplinary group of subject matter experts prior to an emergency to serve as a brain bank for the city. The timeline in an emergency is rapid, and patients will present to hospitals regardless of public health or clinical guidance being available. Currently, conflicting standards are too often communicated to the public and the front-line staff. This group of experts should engage in dialogue regarding crisis standards and clinical care protocols for health-care delivery systems during an outbreak to produce messaging that is consistent, reliable, reproducible, and relevant to the population.

The relationships formed in the brain bank in the group, through collaborations and, ideally, regular exercises, also hold the potential to improve operations during an emergency. During an event, this pre-established brain bank could provide intermittent guidance based on the best available data and provide consistent and reliable communication between public health agencies and health-care delivery systems. Encouraging collaboration and improving coordination among stakeholders on various levels will be essential to ensuring an effective response, as it could reduce duplicative efforts and requests for information, which burden systems already at or above safe capacity. These efforts would also improve transparency and could streamline nomenclature by means of a common language for case definitions and guidance.

Finally, for frontline health-care workers, improved trainings represent another actionable recommendation for improving preparedness. To move the needle of preparedness, NYC H+H System-wide Special Pathogens Program has developed a number of training resources for frontline clinicians both within its health-care delivery system and open to the national audience to maintain competency and readiness during potential outbreak events. This includes (1) a 1-day, 8-h immersive simulation course that offers didactic and hands-on clinical simulation with focus on safety precautions while in personal protective equipment, live donning/doffing technique, and exercise on patient transfer and transport scenarios, including clinical stations for immediate bodily fluid disinfection and clean up and collection of laboratory specimens; (2) using a mobile emergency department, a team of emergency department staff are submerged into a severe respiratory disease outbreak simulation based on the 2003 outbreak of severe acute respiratory syndrome (SARS) with increasing patient acuity. Using innovative teaching methods and clinical simulation technology with part-task and hi-fidelity simulators, each team is presented with realistic patient scenarios; (3) ongoing 1-h in-service trainings for frontline clinicians on how to best identify, isolate, implement infection control measures, notify and preliminarily managing highly infectious disease patients; and (4) continue to practice what we preach and test our plans and processes through ongoing drills and exercises varying in scope, scenario and intensity throughout the acute, postacute, and ambulatory service lines. All 4 training offerings and operations- and discussion-based exercises can be on the NYC H+H system’s website in the form of templates for other sites to customize and use. We strongly urge other health systems to adopt, customize, and use these resources to ensure all health-care facilities are given the ongoing opportunity to train and exercise. After all, we are as strong as our weakest link.

More specifically, Just-In-Time (JIT) Training will allow providers to have the minimum necessary skills in advance of an outbreak and then provided the last set of actionable skillsets just prior to deployment. As most skills degrade over time, JIT Training improves clinical skills to prepare individuals for the management of atypical tasks during emergencies within their scope of practice; this will be essential for the preservation of resources during an emergency. Workshop participants suggested that regional training centers could train key staff in health-care delivery systems and expand local capacities for both proactive and reactive trainings that would improve outbreak response.

This workshop and the associated recommendations presented above represent a step toward improving urban pandemic preparedness. Our goal was intentionally broad and high level to accomplish more than simply working through a scenario, but to emphasize the importance of collaboration, distribution of scarce shared resources, and joint decision-making. We are the most resource-rich country in the world, yet we chronically underutilize integrated decision-making to improve the value and quality care for our patients. We have a moral obligation to appropriately allocate resources; from grant funds, to staff, to equipment and supplies, we must distribute each thoughtfully and justifiably, with a focus on our frontlines. We must continue this important work and to think critically, discuss openly, and act humbly when preparing for pandemics and other public health emergencies in the cities so many of us call home, because after all, ready or not, patients will present.