Transcript Flowers - Disaster Doug

To introduce local Health Officers, Public Health
Directors, LEMSA Administrator, and LEMSA
Medical Director and other staff to the Altered
Standard of Care Pre-Planning Guide.
The Altered Standard of Care Pre-Planning Guide
is designed as a tool to assist local emergency
planners with modifying the current EMS delivery
system in response to a catastrophic incident.
• Developed with HPP Year 8 grant funds
• Based upon best practices and source
documents including:
– Santa Clara County Altered Standards Tool,
– San Francisco County Altered EMS Protocols,
– CDC and NHTSA guidelines
• Designed as an all-hazards tool for any type of
disaster, including:
–
–
–
–
Severe flooding
Earthquakes
Pandemic Outbreak
Other catastrophic incidents
EXERCISE SCENARIO
WORLD WIDE
IMPACT
• In early February, confirmed reports from the
U.S. Centers for Disease Control revealed a
novel strain of the influenza virus.
The World Health Organization declared a global
pandemic alert as more than 214 countries and
overseas territories or communities worldwide
have reported laboratory confirmed cases of the
novel virus.
As of last week, most developed countries
reported widespread infection, including at least
18,449 deaths.
Community Mitigation measures include school
closures, cancellation of mass gatherings, isolation
and quarantine, and other social distancing
measures.
• Health care systems experiencing significant
stress; reporting regional surges in hospital,
emergency department, and outpatient visits.
• Some countries reporting hospital bed,
equipment and medication shortages.
NATIONAL
IMPACT
CDC is reporting that the most impacted
populations include:
– Children and young adults
– Persons with underlying chronic medical conditions
(e.g. chronic lung disease, heart disease,
immunosuppression, neurological and
neurodevelopment diseases)
– Pregnant women
– Indigenous populations
– Possible risk groups: Obesity (Body Mass Index ≥35),
Extreme/Morbid obesity (Body Mass Index ≥40)
Oseltamivir (Tamiflu) and zanamivir are the only
FDA-approved antiviral drugs effective against this
virus.
President Obama has signed a proclamation
declaring this influenza pandemic a National
Emergency to facilitate our ability to respond to the
pandemic by enabling – if warranted – the waiver
of certain statutory Federal requirements for
medical treatment facilities.
In particular, this proclamation is aimed at
providing HHS the ability to waive legal
requirements that could otherwise limit the ability
of our nation’s health care system to respond to
the surge of patients with the novel influenza virus.
• Hospitals request to set up an alternative
screening location for patients away from the
hospital’s main campus (requiring waiver of
sanctions for certain directions, relocations or
transfers under EMTALA).
• Hospitals request to facilitate transfer of patients
from ERs and inpatient wards between hospitals
(requiring waiver of sanctions under EMTALA
regulations).
• Critical Access Hospitals requesting waiver of 42
CFR 485.620, which requires a 25-bed limit and
average patient stays less than 96 hours.
• Skilled Nursing Facilities requesting a waiver of
42 CFR 483.5, which requires CMS approval
prior to increasing the number of the facility’s
certified beds.
Gubernatorial Declaration
NOW, THEREFORE, I, EDMUND G. BROWN JR.,
Governor of the State of California, in accordance with the
authority vested in me by the California Constitution and
the California Emergency Services Act, and in particular
California Government Code sections 8558(b) and 8625,
find that conditions of extreme peril to the safety of person
and property exists within the State of California and
HEREBY PROCLAIM A STATE OF EMERGENCY in
California.
Gubernatorial Declaration (Cont.)
IT IS HEREBY ORDERED that all agencies and
departments of state government utilize and employ state
personnel, equipment, and facilities as necessary to assist
the State Department of Public Health and the Emergency
Medical Services Authority in immediately performing any
and all activities designed to prevent or alleviate illness and
death due to the emergency, consistent with the State
Emergency Plan as coordinated by the California
Emergency Management Agency.
LOCAL IMPACT
Butte: Both Oroville Hospital and Feather River Hospital
reporting >100% capacity. Ambulance turn-around times
greatly delayed (60 - 90 minutes).
Colusa: Colusa Regional Medical Center has converted
the Physical therapy and Outpatient areas into additional
inpatient beds, and also reports significant delays in
ambulance response.
• Nevada: Tahoe Forest and Sierra Nevada Memorial
Hospital are both using surge tents and have created
surge beds within their facilities. Dispatch is complaining
about lack of available ambulances and lack of mutualaid resources.
• Placer: All three hospitals have implemented internal
surge plans. Kaiser and Sutter Roseville have been in
discussions with Public Health to convert a portion of the
Maidu Center into an ACS for additional inpatient beds.
• Shasta: Fire personnel in Redding reported an incident
in which they performed CPR on-scene for 29 minutes
before ambulance arrival. 5 ambulances are currently
being held at Shasta Regional Medical Center with
patients on their gurneys, 2 of these have been waiting
more than 90 minutes.
• Siskiyou: Mercy Medical Center Mt, Shasta and
Fairchild Medical Center are reporting zero inpatient
beds, and are holding multiple admissions in the ED.
911 callers are complaining of being put on hold, and
ambulances have delayed turnaround times.
• Sutter: Fremont Medical Center has a full census, and is
reported no available beds. Bi-county ambulance has
staffed two additional units, and are complaining about
the ED status and turnaround times at Rideout.
• Tehama: Due to the recent MCI at the Red Bluff Airport,
St Elizabeth Hospital has been dealing with several
trauma patients, and has no inpatient beds available.
Fire personnel have been unavailable to assist on
medical calls due to the MCI and fire.
• Yolo: The Yolo Emergency Communications Agency
has implemented their Emergency Rule Stage 3 for
suspending pre-arrival instructions to attempt to respond
to the increased 911 medical-aid requests. Sutter Davis
and Woodland Memorial have both activated internal
surge plans, and are holding admits in the ED. AMR
Yolo is reporting significant delays at the ERs, and are
unable to staff additional units due to sick calls.
Yuba: Rideout is reporting a significant staffing crisis due to
sick call-ins. The HERT team has set up surge tents in the
parking lot to receive/triage patients. However, ambulance
personnel are reporting that there are no nurses staffing
the triage area, and there are three ambulances waiting
outside for more than an hour.
• In response to overwhelming numbers of local requests
from MHOACs, Public Health Departments, ambulances,
and hospitals; S-SV has been in contact with EMSA and
the RDMHSs in Region III and Region IV regarding
ambulance mutual-aid, and no additional resources are
available at this time.
• Since outside resources are unavailable, each
operational area must determine how to continue to
support the 911 system with the current local resources.
ALTERED
STANDARD
ORDERS FORM
• It’s a tool…not a policy
• Once reviewed, and signed by the MHOAC or EMS
Agency Medical Director it becomes an Emergency
Policy and Protocol
EMERGENCY
Policy and Protocol
• In response to this Pandemic Outbreak,
the EMS Agency staff has met, and would
like to present their proposal to the Health
Officers to get feedback and consensus.
• We are going to review those proposals in
two segments:
– Public Access Changes, and
– Field Protocol Changes
• Following each segment, there will be a
time for open discussion.
IMMEDIATE
DELAYED
MINOR
DECEASED
• Public Access Number/ Website
• Scheduled Transport Center
• Altered 911/EMD triage
By establishing a Scheduled Transport Center the
stress on the 911 system will be significantly
decreased, and will allow dispatchers to manage a
higher call volume and improve call turn-around
times.
Activating this separate center will allow the
Transport Center staff to explore all the
alternatives for the transportation needs of the
calling party.
The Scheduled Transport Center is designed to
coordinate all medical transportation requests from all
system access points including:
•
•
•
•
•
hospitals,
health facilities,
Public Access Number,
911, and
the field.
The Scheduled Transport Center responsibilities
include:
• Augmenting medical transportation with alternative
vehicles: buses, taxis, etc.
• Developing and implementing a medical
transportation scheduling process
• Working with Control Facilities to coordinate the
destinations of all transport resources including
those to possible Alternate Care Sites, clinics, etc.
For Ambulatory Patients
YES
NO
Does the patient have
their own vehicle?
YES
Direct the patient to use
this transportation
resource to seek
medical attention
NO
Does the patient have
friends/family that can
transport them?
YES
NO
Does the patient have
access to public
transportation?
Schedule transport service (taxi, bus, or BLS transport)
For Non-Ambulatory Patients
NO
Is patient able to sit in a
wheelchair
Schedule BLS transport
YES
Schedule wheelchair
transport
Two way radio communication between
the:
• Public Access Number
• 911
PUBLIC
ACCESS
NUMBER
Creating a Public Access Number would greatly
relieve the stress on the 911 system by referring
the public to the appropriate resources without
having to call 911 and utilize emergency
responders unnecessarily.
In July 2000, the Federal Communications
Commission (FCC) reserved the 211 dialing
code for community information and referral
services.
The FCC intended the 211 code as an easy-toremember and universally recognizable
number that would enable a critical connection
between individuals and families in need and
the appropriate community-based organizations
and government agencies.
211 as an option.
The 211 center’s referral specialists:
• interview callers,
• access databases of resources available
from private and public health and human
service agencies,
• match the callers’ needs to available
resources, and
• link or refer them directly to an agency or
organization that can help.
During a disaster or emergency activation, calltakers for the Public Access Number should be
trained to triage calls in a similar fashion as 911
call-takers.
Consideration should be given to staffing the call
center with Registered Nurses.
211 or Other
Public Access Number
Call Taker
Obtain:
• Incident Location
• Call back number
• Patient age
• Level of Consciousness
• Status of breathing
• Chief Complaint
If a call comes into the Public Access Number that
is a medical emergency, the call taker will Instruct
the caller to “Hang up and call 911”
Caller instructed to
call 911
Provide Paramedic
Response
At home care
Medical
Emergency?
Assess the level of
medical need
Higher level of
care
No medical need
If it is determined that the caller has only
minor medical care needs, they may be:
• Given self care or family care
instructions
• Directed to sources of health
information on the internet
Examples of medical web support include:
•
•
•
•
WebMD.com
CDC.Gov (Centers for Disease Control)
Bepreparedcalifornia.ca.gov (CDPH), and
Local Public Health Department websites
If it is determined that the caller needs to be seen
by a medical practitioner they should be
assessed for their ability to obtain necessary
transportation.
If the patient is unable to transport themselves or
have family transport them to their personal
physician, they should be transferred to the
Scheduled Call Center.
If it is determined that the caller has no medical
need, they may be:
• Transferred to other social or public service
call center,
• Referred to other public information
websites,
• Referred to appropriate agency or county
services.
• Discontinue Use of Emergency Medical
Dispatching (EMD) Procedures
• Discontinue Use of Pre-Arrival Instructions
(PAI)
•
Implement Altered Triage Algorithm
This triage system will use the following categories to
rank patients according to severity of need:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.
Needs non-medical community services.
www.disasterdoug.com
IMMEDIATE
DELAYED
MINOR
DECEASED
Reporting Party
Calls 911
911 Call Center
Paramedic
(QRV)
(if any delay in ALS
response, a BLS unit
is dispatched.)
1. “Can pt. talk”
2. “Can pt. walk”
unassisted
NO
YES
ON
SOB
Acute ALOC
Severe Bleeding
Is it a Medical
Emergency?
YES
211 or (7 digit)
Public Access
Center
Nurse Support
Line
Transport Center
Check availability of:
 Family/Friend
 Public Transport
 Dial-a-Ride
 Taxi
 Flu Bus?
NO
Medical Dispatch
YES
Schedule BLS
Transport
(pt call-back-confirm)
www.disasterdoug.com
• The county establishes a Public Access Number
/ Website.
• The EMS Agency to work with providers to
establish the Scheduled Transport Centers.
• Implement Altered EMD Triage Protocols
• Establishing Quick Response Vehicles (QRVs)
• Change in Field Treatment Protocols (e.g. Treat-andRelease, Flu Cache)
• Family/Patient Brochure
• Just-in-Time Training
Quick Response Vehicles
(QRVs)
One solution may be to convert all ALS
ambulances to BLS transport units, allowing
us to place paramedics on Quick Response
Vehicles (QRVs) This implementation will
quickly expand available EMS resources.
www.disasterdoug.com
A Quick Response Vehicle or QRV is a
vehicle that is staffed with at least one
paramedic, and equipped with Advanced Life
Support (ALS) equipment/supplies per local
EMS Agency protocol. Such vehicles may
include: Ambulance supervisor vehicles,
shared resources from other emergency
response agencies (fire, law, public works).
Establishing QRVs will allow the paramedic to:
•
•
•
•
Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call
www.disasterdoug.com
ALTERED FIELD
TRIAGE
This triage system will use the following categories to
rank patients based upon the severity of need.
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.
Needs non-medical community services.
IMMEDIATE
Treat and
Transport
DELAYED
Treat and
Release or
Refer
MINOR
DECEASED
Refer to
Public
Access
Number
Witnessed= Use
First Round
ACLS protocols
Unwitnessed =
refer to public
access number
IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.
www.disasterdoug.com
DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,
normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care
www.disasterdoug.com
MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.
www.disasterdoug.com
DECEASED
Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is no
response the patient would be determined dead in the
field. Family would be given a patient brochure with
the Public Access Number prior to clearing the scene.
www.disasterdoug.com
The EMS Authority is considering approval of
expanding the paramedic scope to include a
Disaster Flu Cache.
This cache may include flu treatment items such
as: powdered Gatorade, Compazine
suppositories, ibuprofen, etc.
The S-SV Medical Director will continue to work
with EMSA to determine if this is viable locally.
www.disasterdoug.com
Family/Patient Brochure
A Family/Patient Brochure should be designed
to be distributed by EMS field personnel to
patients and family members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies
www.disasterdoug.com
The Patient/ Family Brochure
should contain:
• information about the current situation,
explaining the significant impact of the
incident on the population
• health threats, including current and
projected effects
• impact on the hospitals, describing
limited resources and alternatives
• EMS system changes, including changes
in 911 protocols, as well as, what to
expect when EMS responders arrive.
www.disasterdoug.com
The Patient/ Family Brochure
should contain:
• Information regarding the local Public
Access Number for individuals with nonmedical emergencies
• Information regarding Web-based health
information such as the CDC website,
local Public Health website, or other
private sites such as WebMD, etc.
• Information regarding self-care such as
at-home treatment for fever, flu
symptoms, minor first-aid, etc.
www.disasterdoug.com
JUST IN TIME
TRAINING
After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design
www.disasterdoug.com
Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.
www.disasterdoug.com
Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com
Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.
• Establish Quick Response Vehicles (QRVs)
• Alter Field Treatment Protocols (e.g. Treat-andRelease, Flu Cache)
• Develop Patient/Family Brochure
• Conduct Just-in-Time Training
Discussion
• Online training tools: S-SV EMS Agency website at
www.ssvems.com (under the HPP Current & Past Projects link)
• AAR form / evaluation tool will be emailed to HPP Coordinators
and then distributed
• After Action Review:
April 11th HPP Project meeting (AAR and CAP)
Thank you for participating in
the…
Altered Standard of Care Pre-Planning
Guide Exercise.