Transcript AHRQ Slide Template 2004

Not Just Decisions, the Right
Decisions; Not Just Stuff but the
Right Stuff
Sally Phillips, RN, PhD
March 6, 2009
Emergency Management Summit
Tiered Response
 Individual Hospital planning and
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

response
Health care system planning and
response
Regional health care system planning
and response
State level planning and response
Intrastate and Interstate planning and
response
Federal Response
Decisions and Stuff
 Capabilities and Capacities( EXAMPLES)
– Workforce equipment, training, increase numbers,
administrative changes
– Supplies- Caches (ventilators, medications, and
associated space, resupply and receiving
augmented support)
– Beds and space expansions
– Labs
 Requirements to respond
– Planning Scenarios
 System wide expansions and policies
– Home care, primary care, ambulatory services
– Other facilities in system
 Partners in individual hospital mission
– EMS
AHRQ Emergency
Preparedness Resource
Inventory (EPRI)
EPRI Goals
 Enable regions to compile an inventory
of critical resources via a public domain
database tool
 Provide flexible access to inventory data
via a web site
 Provide ability to make emergency
requests and tabulate responses
– What resources do you need?
– What resources can you share?
EPRI Inventory Structure
• Resource Types, Resources
Resource Type (Examples)
Hospital Beds
Physicians
Antibiotics
Facility Capabilities
Resources (Examples)
ICU Beds
Trauma Surgeons
Oral Cipro 500 Mg Doses
Food Preparation Capability
• Location Types, Locations
Location Type (Examples)
Hospitals
Nursing Homes
EMS Agencies
Locations (Examples)
Hospital ABC
Nursing Home XYZ
EMS Agency ABC
• Resources are “Assigned” to Location Types
EPRI Home Page

Inventory Data Entry and
Data Quality

Resource
Requirement Models
 AHRQ Surge Model
– Estimates hospital resources needed to
treat casualties from nine different WMD
scenarios
 Mass Evacuation Transportation
Model
– Estimates transportation resources
needed to evacuate patients from
healthcare facilities
Models and Tools for Mass
Casualty Surge Requirements
Resources for WMD response
Surge Model Scenarios

Biological
– Anthrax
– Smallpox
– Flu Pandemic
– Food Contamination
– Plague
 Chemical
– Chlorine
– Mustard
– Sarin
 Nuclear / Radiological
– 1 KT or 10 KT nuclear device
– Radiological dispersion device (“Dirty bomb”)
– Radiological point source
 Conventional explosive
Surge Model Components
Event
Surge Model
Casualty Module
Pre-hospital
management
Surge
arrivals
Hospital or network
capacity
Surge Model
Hospital Module
Treated
Died
Factors Considered
 Attack location characteristics (e.g., population
density)
 Time delay between attack and when
symptoms present (biological and radiological
scenarios)
 Optional mass prophylaxis (biological and
radiological scenarios)
 Condition of casualties upon arrival at the ED
(e.g., mild vs. severe symptoms)
Hospital Resources in the
Surge Model
 Durable




equipment
Human
resources
Pharmacy
Consumable
supplies
Personal
protective
equipment
 Psychological
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
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
Support
Housekeeping
Lab / Radiology
Mortuary
Nutrition
Casualty Arrivals at Hospitals
(Prophylaxis reduces hospitalizations
from 5,000 to 1,048)
Hospitalized Patients by Day
and Unit
Resource Requirements for
this Scenario
Category
Name
Units
Day of
Peak Need
Amount Needed
on Peak Day
Ancillary: Psychologist
Psychological support
FTE
4
21
Capacity: Floor
Med/Surg Bed
Unit of Use
10
588
Capacity: Ventilator
Mechanical ventilator
Machine
Time
4
94
Engineering: Facility
Engineering
FTE
4
33
Epidemiology: Infection
Control
Patient infection control
FTE
4
51
Equipment:O2 Monitoring
Oxygenation monitoring
equipment
Machine
Time
4
164
Equipment: Vent Tubing
Ventilator equipment
Unit of Use
4
94
Housekeeping: Janitorial
Janitorial/Housekeeping
FTE
4
69
Housekeeping: Laundry
Sheet change
Unit of Use
4
732
Lab/Radiology: Laboratory
Laboratory machines
Machine
Time
4
15
Pharmacy: Antibiotics
Cirprofloxacin or
Doxycycline
400mg/100
mg bid
4
732
Pharmacy: Antibiotics
Rifampin or other 2nd line
agent
600mg po
bid
4
199
Resource Requirements for
this Scenario
Category
Name
Units
Day of
Peak Need
Amount Needed
on Peak Day
PPE: Universal
Universal Precautions PPE
Unit of Use
4
732
Radiology: CXR
Radiology machines
EA (Each)
3
8
Staff: CCM
Intensivists (CCM)
FTE
4
16
Staff: MD
Non-intensivists (MD)
FTE
3
28
Staff: Pharmacist
Pharmacists
(PharmD/RPh)
FTE
5
29
Staff: Rad Tech
Radiologic Technicians
FTE
3
8
Staff: RN
Non-critical care nurses
(RN/LPN)
FTE
3
126
Staff: RT
Respiratory Therapists
(RT)
FTE
4
33
Supplies: IV set
Antibiotics intravenous
infusion set
Unit of Use
4
465
Supplies: IV Set
Intravenous infusions set
Unit of Use
4
543
Supplies: Laboratory
Laboratory supplies
Unit of Use
4
349
Supplies: Oxygen
Oxygen (O2)
Unit of Use
4
283
Comparison of Required
and Available Resources
 Display of staffing levels from HHS Area
Resource File
Adult Med/Surg Bed
Adult Mechanical ventilator
Adult ICU Bed
Pediatric Mechanical ventilator
Pediatric Med/Surg Bed
Adult Ventilator Circuit
Pediatric ICU Bed
Pediatric Ventilator Circuit
Burn Bed
Closed circuit suction catheter 14F
Operating Room
Closed circuit suction catheter 8-12F
Airborne Isolation Room
Humidification and Flitration Unit (HMEF)
Intensivists (CCM)
Endotracheal tube, 3mm ID
Critical care nurses (CCN)
Endotracheal tube, 4mm ID
Surgeons
Endotracheal tube, 5mm ID
Non-intensivists (MD)
Endotracheal tube, 6mm ID
Non-critical care nurses (RN/LPN)
Endotracheal tube, 7mm ID
Pharmacists (PharmD/RPh)
Endotracheal tube, 8mm ID
Respiratory Therapists (RT)
Laryngoscope blades, adult
Mortuary
Laryngoscope blades, pediatric
Ventilator Oxygen (O2)
Laryngoscope handles
NC Oxygen (O2)
Endotracheal stylette
Pulse oximeter
Resuscitation Bag, adult
Finger pulse oximeter strip
Resuscitation Bag, pediatric
End tidal CO2 detector, adult
Radiology machines
End tidal CO2 detector, pediatric
Radiology supplies
Temperature monitoring equipment
Chemistry Laboratory machines
Urine output--Foley catheter 8F-12F
Chemistry Lab supplies
Urine output--monitor bag
Hematology Laboratory machines
BP cuffs, adult
Hematology Lab supplies
BP cuffs, pediatric
Micro/Virology Laboratory machines
Microbiology/Virology Lab supplies
Surge Model Treatment Paths
Arriving
Casualty
Emergency
Department
Dead
Or
Discharged
Patients
Floor
x1
ICU
LoS value
Mean
Path Probabilities
ED
ED
ED
Floor Floor
ED
ED
Floor ICU
ICU
ED
ED
ED
Floor Floor ICU
Floor Floor ICU
Disch Death Disch Death Death Disch Death Death
0%
0%
89%
5%
1%
4%
0%
0%
0%
0%
4%
0%
0%
1%
0%
21%
Mortality rate
Low
Calculate
SCENARIO
Flu Moderate Hospitalized
Flu Severe ICU
STREAM
moderate
severe
Path Probabilities
ED
ED
ED
Floor Floor
ED
ED
Floor ICU
ICU
ED
ED
ED
Floor Floor ICU
Floor Floor ICU
Disch Death Disch Death Death Disch Death Death
0%
0%
89%
5%
1%
4%
0%
0%
0%
0%
4%
0%
0%
1%
0%
21%
Overall probabilities
ED
ICU
Floor
Disch
1%
71%
Expected Length of Stay
ED
ICU
Floor
E[LoS] E[LoS] E[LoS]
Death P(Disch) P(Death) Sum Disch Dead
Overall
0%
94%
6% 100%
6.48
5.10
6.39
4%
75%
25% 100%
13.64
6.35
11.84
Surge Model uses NIGMS MIDAS
(Epicast) Flu Model Output
Example of Surge Model Output:
Ventilator Requirement over Time
Calculating Patient Type-Specific
Resource Consumption
 First define average resource
requirements per unit, per patient type,
and per time interval
 Calculate, based on LOS and
death/transfer rates, the number of
patients in any resource consumption
category at any given time
Hospital Bed Availability and Patient
Tracking System (HAvBED)
 Prototype “real-time” standardized data reporting tool
– Enhance system/region’s ability to care for surge of
patients from public health emergency (e.g., flu)
– Provides timely reporting of bed status data in an
emergency (includes GIS)
 Nationwide scope: prototype participants (Dec, 2005)
 Standard Bed Reporting categories
http://ahrq.gov/research/havbed/definitions.htm
 Sustainable Bed Availability Reporting System
(HAvBED2)
Delivered to DHHS 12/07
Discharge Criteria for Creation
of Hospital Surge Capacity
The Grant focus was the development of:
 an easy-to-apply method for pre-designating
hospitalized patients suitable for early
discharge in the event of a disaster.
 a tool tested and evaluated in comparison with
the current ad hoc method of identification of
such patients.
Kelen, G. Johns Hopkins University
Current development of a decision support
tool underway with the Disaster Alternative
Care Site Project with ASPR on this topic
Project Xtreme Cross
Training Video
Model for Health Professional’s
Cross Training for Mass Casualty
Respiratory Needs
 Tool for assisting with mechanical
ventilator staff surge
 Curriculum developed for ‘just in
time’ training for SNS
 Identifies appropriate health care
professionals to be trained and used
in a surge situation
http://ahrq.gov/prep/projxtreme/
Mass Evacuation
Transportation Model
A planning tool for estimating the
transportation resources required to
evacuate healthcare facilities
– Estimate evacuation time, given
transportation constraints
– Or, estimate transportation assets
needed to evacuate within a time
constraint
The Model Considers
 Location of evacuating and receiving
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
facilities
Patient transportation requirements
Availability of transport vehicles
Surge capacity of receiving facilities
Traffic congestion
Illustrative Hospital Evacuation
Illustrative Hospital Evacuation
Model Pilot Tests
 New York City (April 2006)
– Category 4 hurricane
– Evacuation of 24 hospitals and 61 nursing
homes in coastal areas (approximately
24,000 patients)
– Planned evacuation (72 hours notice)
 Los Angeles (May 2007)
– Major earthquake
– Evacuation of 3 hospitals (900 patients)
Evacuation Time (days)
Changes to ALS
Availability (Los Angeles)
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
0
10
20
30
40
Number of ALS units
50
60
70
Changes to Standard of
Care (Los Angeles)
120
100
Hours
80
ALS
60
BLS
40
20
0
Standard
50% ALS->BLS
ALS<->BLS
Mass Medical Care with Scarce
Resources: Community Planning
Guide
 Provides community planners, as
well as planners at the
institutional, State, and Federal
levels, with information to help
plan for and respond to a mass
casualty event
 Guide is written by leading experts
in 6 areas related to mass
casualty care: prehospital care,
hospital and acute care,
alternative care sites, palliative
care, ethical issues, and legal
considerations.
http://www.ahrq.gov/research/mce/
Mass Medical Care with Scarce
Resources: A Community Planning Guide
Collaboration between AHRQ and ASPR
 Ethical Considerations in Community
Disaster Planning
 Assessing the Legal Environment
 Prehospital Care
 Hospital/Acute Care
 Alternative Care Sites
 Palliative Care
 Influenza Pandemic Case Study
Ethical Principles
 Greatest good for greatest number
 Ethical process requires
– Openness
– Explicit decisions
– Transparent reporting
– Political accountability
 Difficult choices will have to be made;
the better we plan the more ethically
sound the choices will be
Legal Issues
 Advance planning and issue
identification are essential, but
not sufficient
 Legal Triage – planners should
partner with legal community for
planning and during disasters
Questions and Discussion
http://www.ahrq.gov/prep/
Publications & Tools
 To order a copy of reports, tools, or
resources:
– contact the AHRQ Publications
Clearinghouse at 800-358-9295
– Send an E-mail to
[email protected].
For More Information
Contact: Sally Phillips, RN, PhD
Email:
[email protected]