Transcript presentation - PHS Commissioned Officers Foundation for the

Hospital Preparedness for
Emergency Response:
United States, 2008
Richard Niska, MD, MPH, FACEP
Captain, USPHS
Iris M. Shimizu, PhD
National Center for Health Statistics
22 June 2011
Objective
Summary of hospital preparedness for
responding to public health emergencies:
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Mass casualties
Epidemics of naturally occurring diseases
Prior work
Bioterrorism and Mass Casualty
Preparedness Supplement
2003-2004
 National Hospital Ambulatory Medical Care
Survey (NHAMCS)
 Funded by Office of the Assistant Secretary
for Planning and Evaluation (OASPE)
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Publications from 2003-2004 supplement
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Hospital collaboration with public safety organizations on bioterrorism response. Prehospital
Emergency Care; 2008; 12:12-17.
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Emergency response planning in hospitals, US: 2003-04. Advance Data from Vital and Health
Statistics; 2007; 391. www.cdc.gov/nchs/data/ad/ad391.pdf
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Percentage of hospitals with staff members trained to respond to selected terrorism-related
diseases or exposures – NHAMCS, US, 2003-04. MMWR. 2007; 56(16):401.
www.cdc.gov/mmwr/preview/mmwrhtml/mm5616a6.htm
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Training for terrorism-related conditions in hospitals: US, 2003-04. Advance Data from Vital and
Health Statistics, 2006; 380. www.cdc.gov/nchs/data/ad/ad380.pdf
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Percent of hospitals having plans or holding drills for attacks by explosion or fire. MMWR, 2005;
54(42). www2c.cdc.gov/podcasts/download.asp?f=1096061&af=h&t=1
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Bioterrorism and mass casualty preparedness in hospitals: US, 2003. Advance Data from Vital
and Health Statistics, 2005; 364. www.cdc.gov/nchs/data/ad/ad364.pdf
Current work
Pandemic Emergency Response
Preparedness Supplement – 2008
Parent survey: NHAMCS
 Again funded by OASPE
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Methods:
NHAMCS

NHAMCS uses a national probability sample:
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U.S. nonfederal general and short-stay hospitals
Data weighted to produce national estimates
Collects facility & visit level hospital characteristics
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Facility level: emergency response supplement
Visit level: emergency and outpatient department records
Methods:
Emergency response supplement
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Eight-page survey instrument
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Delivered on site to hospital administrator by U.S.
Census Bureau field representative
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Self-administered by hospital staff member
deemed appropriate by administrator
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Collected later by Census field representative
Emergency response plans
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Scenarios:
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Hospital overcrowding
Disasters
Mass casualties
Disease outbreaks
Terrorism
Choices:
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in emergency response plan
implemented in actual incident during 2007
not in emergency response plan
Percent of hospitals with emergency response plans
for selected types of incidents:
United States, 2008
Percent
95% confidence intervals
(1) NUC-RAD = Nuclear-radiological. (2) EXP-INC = Explosive-incendiary
SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008
Collaboration with outside entities
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Memorandum of understanding (MOU) with other hospitals to accept patients in
transfer from the emergency department when no beds are available:
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
adults
pediatric patients to children’s hospitals
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MOU with regional burn center to accept transfers in the aftermath of an
explosive or incendiary incident
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MOU with other outpatient facilities to augment outpatient services
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Regional communication systems to track:
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emergency department closures or diversions
available intensive care unit beds (adult, pediatric, neonatal)
available hospital beds (adult, pediatric, neonatal)
specialty coverage
Mutual aid agreements with other agencies to share supplies and equipment
Percent of hospitals having memorandum of understanding to accept
emergency department transfers during overcrowding incidents or public
health emergencies, by receiving hospital type:
United States, 2008
Percent
95% confidence intervals
SOURCE: CDC/NCHS, National Hospital Ambulatory Medical
Care Survey, 2008
Expansion of on-site surge capacity
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Cancellation of elective procedures and admissions
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Isolation of airborne disease patients in negative pressure areas
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Conversion of inpatient units to augment intensive care unit (ICU)
capacity
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Alternate care areas with beds, staffing and equipment
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inpatient unit hallways
decommissioned ward space
non-clinical space
Setting up temporary facilities when the hospital is unusable (without
power, flooded, etc.)
Percent of hospitals with plans for selected
components of on-site surge capacity expansion:
United States, 2008
Percent
95% confidence intervals
SOURCE: CDC/NCHS, National Hospital Ambulatory Medical
Care Survey, 2008
Priority setting for limited resources
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Delivery of potassium iodide in response to radioactive release
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Adjusted standards of care for initiation and withdrawal of
mechanical ventilation
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Triage processes for limited intensive care resources
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Regional coordination of standards of care during a pandemic
or other mass casualty incident
Percent of hospitals having written plan for adjusted
standards of care for mechanical ventilators during a
public health emergency:
United States, 2008
SOURCE: CDC/NCHS, National Hospital Ambulatory Medical
Care Survey, 2008
Expanding on-site health
care work force
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Continuity of operations
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Mutual aid agreements to share health care providers
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Advance registration of volunteer health professionals
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Staff absenteeism due to personal impact from the emergency
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On-site child care to maintain staff in hospital
Percent of hospitals having written plan for advance
registration of volunteer health professionals during a
public health emergency:
United States, 2008
SOURCE: CDC/NCHS, National Hospital Ambulatory Medical
Care Survey, 2008
Mass casualty management
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Within-hospital transport of large patient numbers
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Inter-hospital transport of large patient numbers
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Hospital evacuations
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Establishing an on-site large capacity morgue
Percent
Percent of hospitals with plans for selected
components of mass casualty management:
United States, 2008
100
90
80
70
60
50
40
30
20
10
0
95% confidence intervals
94.6
83.9
77.0
62.6
Hospital evacuations
Within-hospital transfer Inter-hospital transfer of
of many patients
many patients
SOURCE: CDC/NCHS, National Hospital Ambulatory Medical
Care Survey, 2008
Establishing large
capacity morgue
Pediatric
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Guidelines on increasing pediatric surge capacity
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Protocol to identify and protect displaced children rapidly
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Tracking accompanied and unaccompanied children
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Reunification of children with families
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Supplies for sheltering healthy displaced children
Percent
Percent of hospitals with plans for selected
components related to pediatrics:
United States, 2008
100
90
80
70
60
50
40
30
20
10
0
95% confidence intervals
42.6
34.0
32.4
31.1
Tracking system for Reunification with Increasing pediatric Identifying and
children
families
surge capacity protecting displaced
children
29.4
Supplies for
sheltering
Special populations
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Communication with:
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deaf patients
blind patients
non-English-speaking patients
Sheltering of:
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mobility-impaired patients
technology-dependent patients
pregnant women
patients with special health care needs
mentally challenged patients
Percent
Percent of hospitals with plans for selected components of
communication with special populations:
United States, 2008
100
90
80
70
60
50
40
30
20
10
0
95% confidence intervals
73.3
58.3
Communication with non-English
speakers
Communication with deaf
patients
47.5
Communication with blind
patients
Percent
Percent of hospitals with plans for selected components
of sheltering special populations patients:
United States, 2008
100
90
80
70
60
50
40
30
20
10
0
95% confidence intervals
47.6
46.7
39.2
39.0
Mobility-impaired Special health care Pregnant women Mentally challenged
needs
33.7
Technologydependent
Communications
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Notification of alerts from health departments
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Participation with local public health departments in
education on influenza vaccination
Mass casualty drills
In how many drills has your hospital participated in the last year?
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Internal drills
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Drills in collaboration with other organizations
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Full scale simulations
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law enforcement, health department, emergency management, fire
department, emergency medical services, hazardous materials teams,
decontamination teams
How many victims (adult, pediatric, elderly)?
How long did the drill last?
Table-top exercises
Drill scenarios
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General disaster and emergency response
Biologic accidents or attacks
• acute decontamination of aerosol exposure
• delayed disease outbreak management
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Severe epidemic or pandemic
Mass vaccinations
Mass medication distribution to:
• hospital personnel
• community
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Chemical accidents or attacks
Nuclear or radiological accidents or attacks
Decontamination procedures
Explosive or incendiary accidents or attacks
Percent of hospitals participating in selected mass
casualty drill scenario types:
United States, 2008
Percent
95% confidence intervals
SOURCE: CDC/NCHS, National Hospital Ambulatory Medical
Care Survey, 2008
Ambulance diversion
Total number of hours in 2007 that:
Emergency department (ED) was on ambulance
diversion
 Hospital was on trauma diversion
 Hospital was on diversion for critical care cases
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Percent
Percent of hospitals on ambulance diversion status, by number
of hours spent on diversion:
United States, 2008
100
90
80
70
60
50
40
30
20
10
0
95% confidence intervals
58.7
16.3
16.2
8.7
None
One to 220 hours
More than 220 hours
Unknown
Cut point based on mean of 220.4 hours spent on diversion. Distribution highly
skewed with median and mode both equal to zero (no diversion hours).
SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008
Key points:
Explosions and fires
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Preparedness for explosions and
fires less frequent than for other
mass casualties
Explosive terrorism infrequent in U.S.
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No incidents since 2001
More common internationally
Fires more common
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15,500 fires in high-rises (1996-1998)
6% of these were in hospitals
U.S. Fire Administration. High-rise fires. Topical Fire Research Series
2(18):1-7. 2002.
Key points:
Emergency department crowding
ACEP recommends that hospitals develop
adequate inpatient surge capacity by:
 canceling elective admissions and
procedures
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opening unused areas
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83.6% of hospitals have plans for this
52.3% have plans to use inpatient hallways
using alternate areas for extra critical
care space
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50.7% of hospitals have this
American College of Emergency Physicians (ACEP). National
strategic plan for emergency department management of
outbreaks of novel H1N1 influenza.
Key points:
Emergency department crowding
Study of adverse events from admitting ED-boarded
patients to inpatient hallway beds during
overcrowding situations.
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Compared to patients admitted to standard beds:
 In-hospital mortality significantly lower for
hallway patients
 ICU transfers significantly lower for hallway
patients
Conclusion: hallway boarding not harmful
Viccellio et al. The association between transfer of emergency
department boarders to inpatient hallways and mortality: a 4-year
experience. Ann Emerg Med 54(4):511-3. 2009.
Key points:
Crisis standards of care
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IOM recommends development of consistent
state crisis standards of care.
Institute of Medicine (IOM) of the National Academies. Guidance for establishing crisis
standards of care for use in disaster situations. Report Brief 1-4. 2009.
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Only 43% of hospitals plan for adjusted standards
of care for ventilators during mass casualties.
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Model for developing such standards:
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Triage system for using ventilators based on
clinical factors related to survival potential
Implemented through health department
Supported by governor declaration
Liability protections in place
Hick & O’Laughlin. Concept of operations for triage of mechanical
ventilation in an epidemic. Acad Emerg Med 13(2):223-9. 2006.
Key points:
Epidemic drills
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ACEP also recommends staging exercises to test
validity of pandemic flu training and plans.
59% of hospitals staged severe epidemic drills.
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33% included mass vaccinations.
23% included community medication distribution.
Survey of health care epidemiologists
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60% felt hospital was well-prepared for pandemic
31% reported shortages of antiviral medications
Important priorities:
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Pandemic flu plan revisions
Mandatory flu vaccination for health care workers
Lautenbach et al. Initial response of health care institutions to
emergence of H1N1 influenza: experiences, obstacles, and
perceived future needs. Clin Infect Dis 50(4):528-30. 2010.
Key points:
Advance registration of health professionals
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Emergency System for Advance Registration of
Volunteer Health Professionals (ESAR-VHP)
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Office of Assistant Secretary of Preparedness &
Response (OASPR)
Grant program for health care facilities to verify
credentials of volunteers during emergencies
Only 56% of hospitals had plans for advance
registration of outside health care professionals.
The report and contact information
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Niska RW, Shimizu IM. Hospital preparedness for emergency
response: United States, 2008. National health statistics reports; no 37.
Hyattsville, MD: National Center for Health Statistics. 2011.
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http://www.cdc.gov/nchs/data/nhsr/nhsr037.pdf
Contact:
 CAPT Rick Niska, MD, MPH

[email protected]