Transcript Does your VOAD have the capacity you think it has?

Surge Is Coming: Is Your Community
Ready?
Lavonne Adams, PhD, RN, CCRN
Texas Christian University Harris College
of Nursing & Health Sciences
April 2011
Definitions of Surge
• “A sudden forceful flow”
• “A sudden or abrupt strong increase”
• Webster’s Dictionary, 2007
Definitions of capacity
• “The ability to perform or produce”
• “The maximum production possible”
• Webster’s Dictionary, 2007
Definitions of Surge Capacity
• No single definition
• No single measurement standard
Surge Capacity
• “The ability to expand care capabilities in
response to sudden or more prolonged
demand”
– The Joint Commission (TJC), 2003, p.19
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”
– Hick, et al., 2004, p. 254
Surge Capacity
• “The ability to obtain adequate staff, supplies
and equipment, structures, and systems to
provide sufficient care to meet immediate
needs of an influx of patients following a
large-scale incident or disaster.”
– Adams, 2009a
Broad Areas of Surge Capacity
• Public health
• Facility-based
• Community-based
• Hick et al., 2004
Community-based Surge Capacity
• Health care organizations are encouraged to
develop community-wide emergency
preparedness plans
• Community-wide emergency plans should
– Enlist the public as a capable, active partner
– Consider alternate sites for providing healthcare
• TJC, 2003
Surge-generating Events
• Contained
– Distinct geographic focus
(even if large)
– Incident site integral
• Population-based
– Not geographically
defined
– Can spread infectiously
Intrinsic Surge Capacity
• Local resources and strategies that can health
care facilities and communities near a disaster
can implement to expand operations
• Bonnett et al., 2007, p.300
Extrinsic Surge Capacity
• Strategies may include:
– Outside help brought into affected area
– Evacuation of survivors to unaffected areas
• Bonnett, et al., 2007, p.301
Evacuee Surge Capacity
• Developed from perspective of an unaffected
area
• Planning begins at community level to
consider multiple issues and services
– transportation, shelter, food, health care, etc.
• Distribution of evacuees should allow
receiving areas to maintain relatively normal
operations
• Bonnett, et al., 2007, pp.302-303
Surge Capacity Benchmarks
• Ability to treat 500 cases per million for
infectious diseases and 50 cases per million
for each of the following incidents: chemical,
toxicity, burns or trauma, and radiation.
• Health Resources and Services Administration (HRSA)
benchmark cited in Schultz & Koenig, 2006
Components of Surge Capacity
• Key components include the “Four S’s”
– Staff
– Stuff
– Structure
– Systems
“The Four S’s”
•
•
•
•
“Staff” refers to personnel
“Stuff” consists of supplies and equipment
“Structure” refers to facilities
“Systems” include integrated management
policies and processes
Examples of Staff
(Health Care)
• Clinical staff
–
–
–
–
–
–
–
nurses
physicians
respiratory therapists
pharmacists
nursing assistants
physical therapists
radiologic technologists
• Non-clinical staff
–
–
–
–
clerical support staff
security specialists
physical plant specialists
communication
specialists
– information technology
specialists
Examples of Staff
(VOAD World)
• Paid staff
• Volunteers
• Type of staff or volunteers depends on
organization’s capabilities and role
Examples of Stuff
(Health Care)
•
•
•
•
•
Cardiac monitors
Medications
Sterile dressings
Intravenous fluids
Personal protective
equipment
•
•
•
•
Beds
Stretchers
Soap
Water
Examples of Stuff
(VOAD World)
•
•
•
•
•
•
•
Bottled water
Hygiene packs
Food
Clothing
Cots
Blankets
Kennels
•
•
•
•
•
•
•
Boxes
Pallets
Pallet jacks
Fork lifts
Computers
Communication devices
Health care “stuff”
Examples of Structures
(Health Care)
• Hospitals
• Extended care facilities
• Community health
centers
• Laboratories
• Public health
departments
Examples of Structures
(VOAD World)
•
•
•
•
•
•
Emergency Operation Centers
Shelters
Collection centers
Distribution centers
Warehouses
Client assistance centers
Examples of Systems
(Health Care)
• Integrated policies and procedures that link
– departments within the health care facility
– health care facility with other health care entities
• EMS
• Home health
• Physician offices
Examples of Systems
(VOAD World)
• Action plans for individual organization or
jurisdiction
• Cooperative agreements with other local
organizations/jurisdictions
• Memoranda of understanding between
individual organization and a state
Surge capacity is not . . .
• Simply one component
• Static
• Standard daily operations
Not Just One Component
• An organization’s surge capacity is more than
the amount of bottled water in its warehouse.
• What about . . .
– staff needed to distribute the water?
– space needed in which to distribute the water?
– fulfilling the organization’s mission to take water
wherever needed?
Not Static
• Multiple components included in surge
capacity
• Each vary in different ways at different times
• As demands on individual components
change, so does the organization’s capacity
Common (Flawed) Assumptions in
Disaster Planning
• Staff will respond when called
• Emergency supplies will be needed by only
one entity
• Desired space will be available when needed
Reality Check
• Assumption: Staff will respond when called
• Reality: Staff experience barriers that affect
their ability and willingness to respond when
called
Limited Staff
• “We have pop-up tents and beds to increase
capacity, we just don’t have pop-up people to
staff them.”
– Public health focus group participant
• Dausey, Buehler, and Lurie, 2007
Reality Check
• Assumption: A jurisdiction expects that
emergency supplies from a voluntary
organization will be ready and waiting for
them to receive
• Reality: Multiple entities simultaneously
experience demands for the same supplies
Example of Effect of Demands on Stuff
• 1000 hygiene kits = Typical supply of hygiene
kits in Organization A’s warehouse in
Anywhere, Anystate, USA
• 750 hygiene kits sent to distribution centers in
response to wildfires in Anystate
• 500 hygiene kits needed in Anywhere
• 1000 - 750 = 250 hygiene kits available
• Stuff component altered
Reality Check
• Assumption: The space planned for a shelter
will be available
• Reality: The desired space is already occupied
(“The church fellowship hall is already
decorated for a wedding reception”)
Plan Outside the Box for Stuff
• Consider ways to cooperate in sharing
available supplies
• Include stuff as an “issue area” in cooperative
disaster drill exercises
Plan Outside the Box
for Structure
• Consider alternate uses of existing facilities
• Develop partnerships with other organizations
for cooperative use of space
Plan Outside the Box for Systems
• Develop partnerships you haven’t considered
• Design disaster drill exercises around “issue
areas” rather than scenarios only
• Have quick education/reference materials that
do not rely on electricity
• Have communication plans that do not rely on
electricity
Potential Barriers to
Staff Availability
• Transportation issues
• Conflicting professional
and voluntary
obligations
• Personal obligations
– child care
– elder care
– pet care
• Concern for personal
safety
• Concern for family
safety
• Adams, 2011
• Adams & Berry, 2010
• French, Sole, & Byers,
2002
• Qureshi, et al., 2005
• Rebmann, English, &
Carrico, 2007
From the Literature . . .
• Only 8-20% of nurses completing bioterrorism
continuing education classes indicated they were
“extremely likely” to respond to various infectious
disease scenarios; 21-64% were “highly likely” to
respond
– Grimes & Mendias, 2010
• No more than 84% and as few 18% of EMS and
emergency department personnel would report to
work during a mass casualty incident
– Syrett, Benitez, Linvingston, & Davis, 2007
More Examples . . .
• Nearly half of a group of public health employees were
likely not to report to work during pandemic influenza
– Balicer, Omer, Barnett, & Everly, 2006
• Only 70% of a group of school health nurses were likely
to report to work during a public health emergency;
90% of the group reported at least 1 barrier to their
ability to report to work
• Qureshi, Merrill, Gershon, & Calero-Breckheimer, 2002
Still More Examples . . .
• Findings of a large study of New York health care
workers indicate that
– Staff experience barriers that affect their ability and
willingness to respond when called
– Staff ability and willingness to report to work during a
disaster varies based on the disaster scenario
• Qureshi, et al., 2005
• A study of Texas nurses and a large study of
Midwestern health care workers support the findings
of Qureshi et al.
• Adams, 2011
• Adams & Berry, 2010
Memorable Comments
• “May be dead”
• “My first priority is to make sure my family is
safe”
• “My family and friends come first”
• “I may be driving to Canada”
• “I may be getting out of Dodge with
husband/pets”
– Health care personnel study participants
• Adams & Berry, 2010
Midwestern Study
• Setting was a community-based health care
network consisting of 6 inpatient facilities
• One of 2 major networks in the area serving a
population of approximately 1.6 million over 9
counties
• Over 2700 employees representing groups
critical to a disaster response were invited to
participate in the anonymous survey;
response rate = 50%
Scenario
Explosion with
mass casualties
Influenza
pandemic
Winter weather
Smallpox
epidemic
Chemical event
SARS outbreak
Radiologic
event
Tornado &
flooding
Able
% (N)
90.6 (1216)
Not Able
% (N)
1 (13)
Not Sure
% (N)
8.1 (109)
87.9 (1179)
2.3 (31)
9.2 (124)
86.6 (1162)
85.8 (1151)
2.8 (38)
2.2 (30)
10.4 (139)
11.7 (157)
85.2 (1144)
82.3 (1105)
72.4 (972)
2 (27)
3.1 (42)
5.8 (78)
12.4 (167)
13.9 (187)
21.4 (287)
71.1 (954)
5.4 (72)
23.1 (310)
Scenario
Explosion with
mass casualties
Winter weather
Influenza
pandemic
Chemical event
Tornado &
flooding
Smallpox
epidemic
SARS
outbreak
Radiologic
event
Willing
% (N)
93 (1248)
Not Willing
% (N)
1.4 (19)
Not Sure
% (N)
5.1 (68)
92.8 (1245)
85.1 (1142)
2.1 (28)
4.2 (56)
4.3 (58)
10.4 (139)
80.9 (1068)
80.4 (1079)
5 (67)
5.7 (76)
13.6 (182)
13.8 (180)
79.4 (1065)
6.2 (83)
13.8 (185)
74.6 (1001)
7 (94)
18 (242)
69.1 (927)
9.2 (124)
21.2 (285)
Significant Correlations
• Responsibility for children produced highest
number of correlations
– Ability to report to work in all scenarios except
winter weather
– Willingness to report to work in all scenarios
except winter weather and influenza pandemic
Texas Study
• Sample included all nurses employed at
participating entities of a North Central Texas
healthcare network
Scenario
Explosion with
mass casualties
Influenza
pandemic
Winter weather
Smallpox
epidemic
Chemical event
SARS outbreak
Radiologic
event
Tornado &
flooding
Able
% (N)
88.6 (273)
Not Able
% (N)
3.6 (11)
Not Sure
% (N)
7.8 (240)
83.1 (256)
4.2 (13)
12.7 (39)
68.9 (211)
77.6 (239)
8.8 (27)
6.5 (20)
22.7 (70)
15.9 (49)
83.1 (256)
81.2 (250)
73.1 (225)
3.9 (12)
4.2 (13)
6.2 (19)
13 (40)
14.6 (45)
20.8 (64)
72.1 (222)
5.5 (17)
22.4 (69)
Scenario
Explosion with
mass casualties
Winter weather
Influenza
pandemic
Chemical event
Tornado &
flooding
Smallpox
epidemic
SARS
outbreak
Radiologic
event
Willing
% (N)
91.2 (281)
Not Willing
% (N)
2.3 (7)
Not Sure
% (N)
6.2 (19)
84.4 (260)
83.1 (256)
5.2 (16)
5.2 (16)
10.1 (31)
11.4 (35)
81.2 (250)
81.8 (252)
5.2 (16)
4.9 (15)
13.3 (41)
13 (40)
72.7 (224)
10.1 (31)
16.9 (52)
73.1 (225)
8.8 (27)
17.9 (55)
68.2 (2100
8.4 (26)
23.1 (71)
Significant Correlations
• Responsibility for children produced almost all
of the significant correlations
– Ability to report to work for all scenarios
– Willingness to report to work for all scenarios
except tornado/flooding and influenza pandemic
Comparison Between Studies
• New York (Qureshi et al)
• Ohio (Adams & Berry)
• Texas (Adams)
Scenario
Explosion
with mass
casualties
Influenza
pandemic
Winter
weather
Smallpox
epidemic
Chemical
event
SARS
outbreak
Radiologic
event
Tornado &
flooding
Able
(OH) %
91
Able (TX) Able (NY)
%
%
89
83
Willing
(OH) %
93
Willing
(TX) %
91
Willing
(NY) %
86
88
83
NA
85
83
NA
87
69
49
93
85
80
86
78
69
79
73
61
85
83
71
81
81
68
82
81
64
75
73
48
72
73
64
69
68
57
71
72
NA
80
82
NA
Plan Outside the Box for Staff
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•
•
•
•
Shared staffing
Cross training
“Just-in-time” training
Clearly identify “need to know” information
Be alert to barriers that affect willingness and
ability of staff to respond
• Consider ways to alleviate barriers
A Few Suggestions
• Encourage prior planning
• Perform disaster drills and include Q&A about
potential barriers
• Develop supportive services for staff
• Provide safety precautions for staff
• Address concurrent employment and
voluntary obligations
• Adams, 2009b
Encourage Prior Planning
• Personal disaster plans
– increase personal wellbeing
– minimize barriers to effective functioning
• Include
– methods for emergency communication
– direction for care of significant others & pets
– protection of documents
Explore Barriers with Your Staff
• Plan disaster drills that include volunteers as
well as paid staff
• Ask about potential barriers to staff members’
availability to respond
• Consider your organization’s policies,
practices, and expectations from the
perspective of your staff members’ life
situations
Drill, Drill, Drill . . .
• If you don’t “drill to failure,” you aren’t drilling
hard enough to find gaps
• Make the scenarios complex enough to test
the system
• Conduct unannounced drills
• Drill on offshifts, weekends, and holidays
• Consider limiting the role of administrators
and managers in the drill
Make It Real . . .
• “The disaster drills where people have a week
or two to get a disaster manual out and
review are just too predictable and easy and
so not real life.”
– Health care personnel study participant
• Adams & Berry, 2010
“Label Them ‘DEAD’”
• “The first couple of administrators on site
should have a ‘DEAD’ triage tag placed on
them and a mouth gag and marked ‘Observer
only’ . . . so you can see who of the staff will
step up and make decisions to the best of
their ability.”
– Health care staff member and study participant
• Adams & Berry, 2010
Consider Developing Supportive
Services
•
•
•
•
Child care
Family care
Short term housing
Staffing plans that allow for shared shifts
– Adams, 2009 (December)
Provide Safety Precautions
•
•
•
•
•
•
Personal protective equipment
Hand hygiene
Sanitation and food safety
Providing adequate time for rest and sleep
Security
Monitor staff’s mental health
• Rebmann, English, & Carrico, 2007
Consider Concurrent Obligations
• Concurrent obligations vary
– Voluntary organizations
– Multiple employers
– Military reserve
– DMAT
• Consider developing shared staffing with
similar organizations
• Develop staffing options that can be feasible
for volunteers who are employed
References
•
•
•
•
Adams, L.M. (2011). Will the nurses show up? Developing realistic disaster
plans. Abstract accepted for poster presentation at Sigma Theta Tau
International 41st Biennial Conference (October 2011), Grapevine, TX.
Adams , L.M., & Berry, D. (2010). Who will show up? Estimating hospital
staff response in disaster. Oral presentation at Emergency Nurses
Association Annual Conference (September 2010), San Antonio, TX.
Adams, L.M. (2009, December). Surge is coming—Is your region really
ready? Journal of Homeland Security. Retrieved from
http://www.homelandsecurity.org/journal/Default.aspx?t=333.
Adams, L.M. (2009a). Exploring the concept of surge capacity. OJIN:
Online Journal of Issues in Nursing, 14. Retrieved from
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/A
NAPeriodicals/OJIN/TableofContents/Vol142009/No2May08/ArticlesPrevious-Topics/Surge-Capacity.aspx
References, cont.
• Adams, L.M. (2009b). Surge ready. Nurse Leader, 7, 8-10.
• Association of Healthcare Research and Quality. (2004). Optimizing surge
capacity: Regional efforts in bioterrorism readiness. Bioterrorism and
Health System Preparedness Issue Brief No. 4. Retrieved April 7, 2008 from
http://www.ahrq.gov/news/ulp/btbriefs/btbrief4.htm.
• Balicer, R.D., Omer, S.B., Barnett, D.J., & Everly Jr., G.S. (2006). Local public
health workers’ perceptions toward responding to an influenza pandemic.
BMC Public Health, 6(99).
• Bonnett, C.J., et al. (2007). Surge capacity: A proposed conceptual
framework. American Journal of Emergency Medicine, 25, 297-306.
References, cont.
• Dausey, D.J., Buehler, J.W., & Lurie, N. (2007). Designing and conducting
tabletop exercises to assess public health preparedness for manmade and
naturally occurring biological threats. BMC Public Health, 7. Retrieved
February 23, 2008 from http://www.biomedcentral.com/1471-2458/7/92.
• French, E.D., Sole, M.L., & Byers, J.F. (2002). A comparison of nurses’
needs/concerns and hospital disaster plans following Florida’s Hurricane
Floyd. Journal of Emergency Nursing, 28, 111-117.
• Grimes, D.E., & Mendias, E.P. (2010). Nurses’ intentions to respond to
bioterrorism and other infectious disease emergencies. Nursing Outlook,
58, 10-16.
• Hick, J.L., et al. (2004). Health care facility and community strategies for
patient care surge capacity. Annals of Emergency Medicine, 44, 253-261.
• The Joint Commission . (2003). Health care at the crossroads. Retrieved
November 21, 2007 from
http://www.jointcommission.org/NR/rdonlyres/5C138711-ED76-4D6F909F-B06E0309F36D/0/health_care_at_the_crossroads.pdf.
References, cont.
• Qureshi, K.A., Merrill, J.A., Gershon, R.R.M., & Calero-Breckheimer, A.
(2002). Emergency preparedness training for public health nurses: A pilot
study. Journal of Urban Health: Bulletin of the New York Academy of
Medicine, 79, 413-16.
• Qureshi, K.A., et al. (2005). Health care workers’ ability and willingness to
report to duty during catastrophic disasters. Journal of Urban Health:
Bulletin of the New York Academy of Medicine, 82, 378-388.
• Rebmann, T., English, J.F., & Carrico, R. (2007). Disaster preparedness
lessons learned and future directions for education: Results from focus
groups conducted at the 2006 APIC Conference. American Journal of
Infection Control, 35, 374-381.
• Schultz, C.H., & Koenig, K.L. (2006). State of research in high-consequence
hospital surge capacity. Academic Emergency Medicine, 13, 1153-1156.
• Syrett, J.I., Benitez, J.G., Livingston III, W.H., & Davis, E.A. (2007). Will
emergency health care providers respond to mass casualty incidents?
Prehospital Emergency Care, 11, 49-54.