Transcript Surge capacity

Emergency Management Strategies for
Identifying and Integrating Community
Resources to Expand Medical Surge Capacity:
Alternate Care Facilities
The National Emergency Management Summit
Washington, DC
February 5, 2008
Stephen V. Cantrill, MD
Department of Emergency Medicine
Denver Health Medical Center
Surge Capacity
Ability to manage a sudden, unexpected
increase in patient volume that would
otherwise severely challenge or exceed the
current capacity of the health care system
Intrinsic:
Facility based
Community based: Alternate Care Facilities
Extrinsic: State / Federal
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Community Based Surge Capacity
Requires close planning and cooperation
amongst diverse groups who have
traditionally not played together
Hospitals
Offices of Emergency Management
Regional planners
State Department of Health
MMRS may be a good organizing force
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Where Have We Been?
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Hospital Reserve Disaster Inventory
Developed in 1950’s-1960’s
Designed to deal with trauma/nuclear
victims
Developed by US Dept of HEW
Hospital-based storage
Included rotated pharmacy stock items
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Packaged Disaster Hospitals
Developed in 1950’s-1960’s
Designed to deal with trauma/nuclear
victims
Developed by US Civil Defense Agency &
Dept of HEW
2500 deployed
Modularized for 50, 100, 200 bed units
45,000 pounds; 7500 cubic feet
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Packaged Disaster Hospitals
Last one assembled in 1962
Adapted from Mobile Army Surgical
Hospital (MASH)
Community or hospital-based storage
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Packaged Disaster Hospital:
Multiple Units
 Pharmacy
 Hospital supplies /
equipment
 Surgical supplies /
equipment
 IV solutions / supplies
 Dental supplies
 X-ray
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 Records/office
supplies
 Water supplies
 Electrical
supplies/equipment
 Maintenance /
housekeeping supplies
 Limited oxygen
support
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Packaged Disaster Hospital
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Packaged Disaster Hospitals
Congress refused to supply funds needed to
maintain them in 1972
Declared surplus in 1973
Dismantled over the 1970’s-1980’s
Many sold for $1
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The Re-Emergence of a Concept:
The Alternate Care Facility
Planning Issues:
Augmentation vs Alternate Facility?
Physical space
Inclusion of actual structure
 Tents, trailers, etc
 Cost? Storage? Ownership?
Structure of opportunity
 Private vs Public sites
 Who grants permission to use?
 Need for decon after use to restore to original function?
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Alternate Care Facility
Planning Issues
It is not a miniature hospital
“Ownership”, command and control?
HICS is a good starting structure
Who decides to open the ACF?
Scope & level of care to be delivered?
Offloaded hospital patients
Primary victim care
Nursing home replacement
Ambulatory chronic care / shelter
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ACF Planning Issues
 Staffing
 Medical Staff
 Ancillary Staff
 Operational support
 Meals
 Sanitary needs
 Infrastructure
 Supplies
 Pharmaceuticals
 Documentation of care
 Security
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ACF Planning Issues
Communications
Hospitals
EMS
Emergency Management: State/Local
Relations with EMS
Rules/policies for operation
Exit strategy
Exercising the plan
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Level I Cache:
Hospital Augmentation
Bare-bones approach
Physical increase of 50 beds
Would rely heavily on hospital supplies
Stored in a single trailer
About $20,000
Within the realm of institutional ownership
Readily mobile - but needs vehicle
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Level I Cache:
Hospital Augmentation
Trailer
Cots
Linens
IV poles
Glove, gowns, masks
BP cuffs
Stethoscopes
(Developed under AHRQ Task Order:
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Rocky Mountain Regional Care Model for Bioterrorist
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Events)
Used During Katrina Evacuee Relief
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Level II Cache: Regional
Alternate Care Facility (ACF)
Significantly more robust in terms of
supplies
Designed by one of our partners, Colorado
Department of Public Health and
Environment
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Level II Cache:
Regional Alternate Care Facility
 Designed for initial support of 500 patients
 Per HRSA recommendations of 500 patient surge per
1,000,000 population
 Modular packaging for units of 50-100 pts
 Regionally located and stored
 Trailer-based for mobility
 Has been implemented
 Approximate price less than $100,000 per copy
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Level II: Level I Plus:
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Ambu bags
Bed pans / Urinals
Medical ID bracelets
Chairs
Cribs
Emesis basins
Forms for documentation
IV sets
Oxygen masks
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Ice packs
Pillows
Privacy screens
Soap
Tables
Duct tape
Adhesive tape
Thermometer strips
Tongue depressors
(Still No Drugs)
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Level III Cache:
Comprehensive Alternate Care Facility
Adapted from work done by US Army
Soldier and Biological Chemical Command
50 Patient modules
Most robust model
Closest to supporting non-disaster level of
care, but still limited
More extensive equipment support
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Work at the Federal Level
DHHS: Public Health System Contingency
Station
Specified and demonstrated
250 beds in 50 bed units
Quarantine or lower level of care
For use in existing structures
Multiple copies to be strategically placed
Owned and operated by the federal government
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Basic Concept: HHS Public Health Service
Contingency Stations
(Federal Medical Stations)
“PHS-CS” 250 Bed Module
Configuration
PHS-CS
Base Support
With
Quarantine
• Administration
PHS-CS
Treatment
PHS-CS
Pharmaceutical
• Support
• Feeding
• Quarantine
• Beds(50)
• Housekeeping
PHS-CS
• First Aid Equipment
Bed Aug
(50)
• Pediatric Care
• Adult Care
• Personal Protective Equipment
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• Primary Care
• Non-Acute Treatment
• Special Needs
• Pharmaceutical
• Special Medications
• Prophylaxis
• Beds
• Bedding
• Bedside Equipment
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Station Layout
Hall A
Feeding Area
HouseCleaning
Storage
Latrine Area and
Patient Wash Area
250 sq. ft.
Waiting
126'-0"
Admin Supp. Pallet
Administration
& Admission
1614 sq. ft.
Tri-fold
Main Power
Distribution Box
Morgue
100 sq ft
Treatment
Area
Isolated
Power
House Support
760 sq. ft.
Medical
Support
Curtain
Pharmacy
First Aid Pack
Curtain
2x7
2x7
Treatment
Area
Tri-fold
Holding
Area
Bio-Med
Tech
Area
399 sq. ft.
Staging Area
To
Generators
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275'-0"
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Folded Litter
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Possible Alternative
Care Facilities
Hotel
Stadium
Recreation Center
School
Church
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ACF Site Selection
What is the best existing infrastructure/site
in the region for delivering care?
(Developed under AHRQ Task Order:
Rocky Mountain Regional Care Model for Bioterrorist Events)
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Rocky Mountain Regional Care Model for Bioterrorist Events
(RMBT) Working Group
FEDERAL Participants
STATE Participants
US Northern Command
Montana DPH
US Air Force
•Office of Surgeon General
Colorado DPHE
•Homeland Security Office
Utah DPH
•Development Center for
Wyoming DPH
Operational Medicine
Colorado US Air Force, Army and
North Dakota DPH
South Dakota DPH
National Guard Bases
US Public Health Service-Region VIII
Colorado Hospital Association
National Disaster Medical System (NDMS)
Colorado Rural Health Center
Department of Veteran Affairs
Medical Center
LOCAL Participants
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Tri- County Health Department
Denver County Health Department
Jefferson County Health Department
Denver Mayor’s Office of Emergency Management
The Children’s Hospital of Denver
Exempla Healthcare
Denver Health
HealthOne
Centura Health
Kaiser Permanente
Front Range Metropolitan Medical Response System
Denver Center for Public Health Preparedness
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ACF Site Selection Tool
ACF infrastructure factors listed on one axis
of a matrix.
Potential ACF sites listed on the other axis
of the matrix.
Relative weight scale for each factor using a
5-point scale comparing factor to that of a
hospital.
Developed as an Excel spreadsheet.
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Potential ACF Sites (pre-selected)
 Aircraft hangers
 Churches
 Community/recreation
centers
 Convalescent care
facilities
 Fairgrounds
 Government buildings
 Hotels/motels
 Meeting Halls
 Military facilities
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 National Guard armories
 Same day surgical
centers/clinics
 Schools
 Sports Facilities/stadiums
 Trailers/tents
(military/other)
 Shuttered Hospitals
 Detention Facilities
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Factors to Weigh in Selection of
an Alternate Care Facility Site
Infrastructure
Total Space and Layout
Utilities
Communication
Other Services
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Factors to Weigh in Selection of
an Alternate Care Facility Site
Infrastructure
Door sizes
Floor
Loading Dock
Parking for staff/visitors
Roof
Toilet facilities/showers (#)
Ventilation
Walls
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Factors to Weigh in Selection of
an Alternate Care Facility Site
Total Space and Layout
Auxiliary Spaces (Rx, counselors, chapel)
Equipment/Supply storage area
Family Areas
Food supply/prep area
Lab/specimen handling area
Mortuary holding area
Patient decon areas
Pharmacy areas
Staff areas
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Factors to Weigh in Selection of
an Alternate Care Facility Site
Utilities
Air conditioning
Electrical power (backup)
Heating
Lighting
Refrigeration
Water
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Factors to Weigh in Selection of
an Alternate Care Facility Site
Communication
Communication (# phones, local/long distance,
intercom)
Two-way radio capability
Wired for IT and Internet Access
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Factors to Weigh in Selection of
an Alternate Care Facility Site
Other Services
Ability to lock down facility
Accessibility/proximity to public transportation
Biohazard & other waste disposal
Laundry
Ownership/other uses during disaster
Oxygen delivery capability
Proximity to main hospital
Security personnel
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Weighted Scale
5 = Equal to or same as a hospital.
4 = Similar to that of a hospital, but has SOME
limitations (i.e. quantity/condition).
3 = Similar to that of a hospital, but has some
MAJOR limitations (i.e. quantity/condition).
2 = Not similar to that of a hospital, would take
modifications to provide.
1 = Not similar to that of a hospital, would take
MAJOR modifications to provide.
0 = Does not exist in this facility or is not
applicable to this event.
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Potential Non-Hospital Site Analysis
Matrix
Ability to lock down facility
Adequate building security personnel
Adequate Lighting
Air Conditioning
Area for equipment storage
Biohazard & other waste disposal
Communications (# phones, Local/Long
Distance, Intercom)
Door sizes adequate for gurneys/beds
Electrical Power (Backup)
Family Areas
Floor & Walls
Food supply/food prep areas (size)
Heating
Lab/specimen handling area
Laundry
Loading Dock
Mortuary holding area
Oxygen delivery capability
Parking for staff/visitors
Patient decontamination areas
Pharmacy Area
Proximity to main hospital
Roof
Space for Auxillary Services (Rx, counselors,
chapel)
Staff Areas
Toilet Facilities/Showers (#)
Two-way radio capability to main facility
Water
Wired for IT and Internet Access
Total Rating/Ranking (Largest # Indicates Best
Site)
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0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Customizing the Site
Selection Matrix
Additional relevant factors or facility sites can
be added to the tool based on your area or
the type of event.
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Issues to Consider
Is each factor of equal weight?
What if another use is already stated for the
building in a disaster situation?
(i.e. a church may have a valuable community
role)
Are missing, critical elements able to be
brought in easily to site?
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WHO needs this tool?
Incident commanders
Regional planners
Planning teams including: fire, law, Red
Cross, security, emergency managers,
hospital personnel
Public works / hospital engineering should
be involved to know what modifications are
needed.
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WHEN should you use this tool?
Before an actual event.
Choose best site for different scenarios so
have a site in mind for each “type”.
Available from:
www.ahrq.gov/research/altsites.htm
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Who has used this tool?
Greece, in preparation for the Olympics
California
Florida
Other states/locations
Available from:
www.ahrq.gov/research/altsites.htm
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The Supplemental Oxygen
Dilemma
 Supplemental oxygen need highly likely in a
bioterrorism incident
 Has been carefully researched by the Armed Forces
 Most options are quite expensive with high
cost/patient
 Many have very high power requirements
 Most require training/maintenance
 All present logistical challenges
 Remains an unresolved issue for civilian ACFs
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And Then The “Other” Problems:
Ventilators:
Currently in US: 105,000
In daily use: 100,000
Projected pandemic need: 742,500
Respiratory Therapists
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Ventilators – Surge Supply
Additional full units - $32,000 each
Smaller units for $6,000 each
Many “Disposable” Units - $65 each
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Respiratory Therapists:
Just-In-Time Training
AHRQ: Project XTREME: www.ahrq.gov/prep/projxtreme/
MD
RT
Trainee
Trainee
RT
Trainee
Trainee
Trainee
Trainee
Trainee
Trainee
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
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ACF Ideal Staffing:
33 Per 12 Hour Shift
 Physician [1]
 Physician extenders
(PA/NP) [1]
 RNs or RNs/LPNs [6]
 Health technicians [4]
 Unit secretaries
[2]
 Respiratory Therapists [1]
 Case Manager
[1]
 Social Worker
[1]
 Housekeepers
[2]
 Lab
[1]
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





Medical Asst/Phlebotomy [1]
Food Service
[2]
Chaplain/Pastoral [1]
Day care/Pet care
Volunteers
[4]
Engineering/Maintenance
[.25]
 Biomed
[.25]
 Security
[2]
 Patient transporters [2]
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MEMS ACC guidelines
Emergency System for Advanced Registration
of Volunteer Health Professionals:
ESAR-VHP
State-based registration, verification and
credentialing of medical volunteers
Should allow easier sharing of volunteers
across states
Still missing:
Liability coverage
Command and control
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Medical Reserve Corps
Local medical volunteers
No corps unit uniform structure
330 units of 55,000 volunteers
Deployments do not qualify for FEMA
reimbursement
Liability concerns are still an issue
ESAR-VHP may help with credentialing
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Development of Gubernatorial
Draft Executive Orders
Developed by the Colorado Governor’s
Expert Emergency Epidemic Response
Committee (GEEERC)
Multi-disciplinary
20 different specialties/fields (from attorney
general to veterinarians)
To address pandemics or BT incidents
Work started in 2000
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Development of Gubernatorial
Draft Executive Orders
 Declaration of Bioterrorism/Pandemic Disaster
 Suspension of Federal Emergency Medical
Treatment and Active Labor Act (EMTALA)
 Allowing seizure of specific drugs from private
sources
 Suspension of certain Board of Pharmacy
regulations regarding dispensing of medication
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Development of Gubernatorial
Draft Executive Orders
 Suspension of certain physician and nurse
licensure statutes
 Allows out-of-state or inactive license holders to
provide care under proper supervision
 Allowing physician assistants and EMTs to
provide care under the supervision of any licensed
physician
 Allowing isolation and quarantine
 Suspension of certain death and burial statutes
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Katrina: ACF Lessons Learned
Importance of regional planning
Importance of security: uniforms are good
Advantages of manpower proximity
Segregating special needs populations
Organized facility layout
Importance of ICS
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Katrina: ACF Lessons Learned
The need for “House Rules”
Importance of public health issues
Safe food
Clean water
Latrine resources
Sanitation supplies
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Available from AHRQ:
www.ahrq.gov/research/mce/mceguide.pdf
Contents:
 Ethical considerations
 Legal aspects
 Prehospital care
 Hospital/Acute care
 Alternative care sites
 Palliative care
 Pan-flu case study
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Disaster Alternate Care Facilities
Agency for Healthcare Research and Quality
Contract No. HHSA290200600020
Task Order No. 4
Review and Revise the Alternative Care
Site Selection Tool
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Task Order
Review AARs and Lessons Observed from:
Response to Hurricanes Katrina and Rita
 - Sites such as Superdome, Convention Center
Use of Federal Medical Stations
NDMS DMATs
Use of other mobile assets
State experiences in site selection
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Task Order
Review, reconsider, revise site selection tool
Develop draft staffing and resource
requirements for a full range of ACFs
Develop draft ACF conops
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Summary
We are rediscovering some old concepts
Supplemental oxygen and respiratory
support remain problems
Surge staffing facilitation requires advance
planning at multiple levels and may still fail
Developing medical surge capacity requires
close planning and cooperation amongst
diverse groups who have traditionally not
played together
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