computer-aided design nathaniel hupert, m.d., m.p.h. assistant professor of public health and...
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Computer-Aided DesignComputer-Aided DesignNathaniel Hupert, M.D., M.P.H.Nathaniel Hupert, M.D., M.P.H.
Assistant Professor of Public Health and MedicineAssistant Professor of Public Health and MedicineDivision of Outcomes and Effectiveness ResearchDivision of Outcomes and Effectiveness ResearchWeill Medical College of Cornell UniversityWeill Medical College of Cornell University
Guiding QuestionsGuiding Questions
What are the critical components of a What are the critical components of a mass vaccination campaign?mass vaccination campaign?What role can spreadsheet models play in What role can spreadsheet models play in forecasting resource requirements for forecasting resource requirements for mass vaccination campaigns?mass vaccination campaigns?What are the limitations of computer What are the limitations of computer modeling in developing mass vaccination modeling in developing mass vaccination plans?plans?
Components of Mass Prophylaxis PlanComponents of Mass Prophylaxis Plan
Created by the Department of Public Health, Weill Medical College of Cornell University, NYCOEM, and NYCDOHMH
SAMPLE PATIENT FLOW DIAGRAM FOR MASS ANTIBIOTIC DISPENSING
Ambulance Bus
Drug Delivery
Entry
TriageArea
Medical Evaluation
DrugDispensing
Hospital
Exit
Airport
VERY SICK GET TRANSPORTTO MEDICAL FACILITY
HEALTHY PEOPLE GET PROPHYLAXISAMBULATORY SICK GET TREATMENT
SAMPLE PATIENT FLOW DIAGRAMFOR MASS ANTIBIOTIC DISPENSING
Created by the Department to Public Health, Weill Medical College of Cornell Univeristy, NYCOEM, and NYCDOHMH
Figure 1: Basic dispensing center design
Non-Infected Need Transport
Infected Need Transport
Non-Infected
Infected
TRIAGE
EVALUATION DISPENSING
ASSISTANCE WITH TRANSPORTATION TO HOSPITAL
SENT HOME
R
SENT TO HOSPITAL
SCHEMATIC FLOW THROUGH SIMPLE DISPENSING MODEL
Steady-state assumptionSteady-state assumption
Steady state develops if Steady state develops if == RR//STSTwherewhere RR==patient arrival patient arrival raterate
S = # staffS = # staff TT==mean service timemean service time
• When When ==then S = RT, orthen S = RT, orStaff required at
a station=
Rate of patient arrival at that
station
Mean station processing time
per patientX
SCHEMATIC SCHEMATIC FLOW THROUGH FLOW THROUGH WEILL/CORNELL WEILL/CORNELL SMALLPOX SMALLPOX VACCINATION VACCINATION MODELMODEL
CR
ISIS
CO
UN
SE
LIN
G
HOME
GREETING/ENTRYSCREENING
FORMDISTRIBUTION
TRIAGE
MEDICAL/CONTACT
EVALUATION
Transport to MedicalCare Facility
WITNESSEDCONSENT &
VACCINATIONFORM
COLLECTION& EXIT
COUNSELINGFORM
COLLECTION& EXIT
COUNSELING
BRIEFING,CONSENT
SUSPECTBRIEFING,CONSENT
Not Suspect Caseor Contact Post-Event
Component:Suspect Cases and
ContactsFORMDISTRIBUTION
FORMDISTRIBUTION
BRIEFING,CONSENT
WITNESSEDCONSENT &
VACCINATION
CRISISCOUNSELING
HOME
QUARANTINEFACILITY
FORMCOLLECTION &
EXITCOUNSELING
POST-EVENT CONTACT PRECAUTION AREA
C
A1
A2+A3[=0% IF PRE-
EVENT]
HOME
“Anyone not feeling well [or who thinks they may have come incontact with someone with smallpox], come this way, please”
B
B
C
B
A
A4
QUARANTINECOUNSELING
D
D
Place N95 mask on patient
DECLINEVACCINATION
CRITICAL
WITNESSEDCONSENT &
VACCINATION
TESTING
CONTRAINDICATIONor DECLINE
TESTING
CONTRAIND.OR DECLINE
R
Weill/Cornell Weill/Cornell Smallpox Smallpox Vaccination Vaccination Staffing Staffing ModelModel
CR
ISIS
CO
UN
SE
LIN
G
HOME
GREETING/ENTRYSCREENING
FORMDISTRIBUTION
TRIAGE
MEDICAL/CONTACT
EVALUATION
Transport to MedicalCare Facility
WITNESSEDCONSENT &
VACCINATIONFORM
COLLECTION& EXIT
COUNSELINGFORM
COLLECTION& EXIT
COUNSELING
BRIEFING,CONSENT
SUSPECTBRIEFING,CONSENT
Not Suspect Caseor Contact Post-Event
Component:Suspect Cases and
ContactsFORMDISTRIBUTION
FORMDISTRIBUTION
BRIEFING,CONSENT
WITNESSEDCONSENT &
VACCINATION
CRISISCOUNSELING
HOME
QUARANTINEFACILITY
FORMCOLLECTION &
EXITCOUNSELING
POST-EVENT CONTACT PRECAUTION AREA
C
A1
A2+A3[=0% IF PRE-
EVENT]
HOME
“Anyone not feeling well [or who thinks they may have come incontact with someone with smallpox], come this way, please”
B
B
C
B
A
A4
QUARANTINECOUNSELING
D
D
Place N95 mask on patient
DECLINEVACCINATION
CRITICAL
WITNESSEDCONSENT &
VACCINATION
TESTING
CONTRAINDICATIONor DECLINE
TESTING
CONTRAIND.OR DECLINE
R
PRE-EVENT
Weill/Cornell Weill/Cornell Smallpox Smallpox Vaccination Vaccination Staffing Staffing ModelModel
CR
ISIS
CO
UN
SE
LIN
G
HOME
GREETING/ENTRYSCREENING
FORMDISTRIBUTION
TRIAGE
MEDICAL/CONTACT
EVALUATION
Transport to MedicalCare Facility
WITNESSEDCONSENT &
VACCINATIONFORM
COLLECTION& EXIT
COUNSELINGFORM
COLLECTION& EXIT
COUNSELING
BRIEFING,CONSENT
SUSPECTBRIEFING,CONSENT
Not Suspect Caseor Contact Post-Event
Component:Suspect Cases and
ContactsFORMDISTRIBUTION
FORMDISTRIBUTION
BRIEFING,CONSENT
WITNESSEDCONSENT &
VACCINATION
CRISISCOUNSELING
HOME
QUARANTINEFACILITY
FORMCOLLECTION &
EXITCOUNSELING
POST-EVENT CONTACT PRECAUTION AREA
C
A1
A2+A3[=0% IF PRE-
EVENT]
HOME
“Anyone not feeling well [or who thinks they may have come incontact with someone with smallpox], come this way, please”
B
B
C
B
A
A4
QUARANTINECOUNSELING
D
D
Place N95 mask on patient
DECLINEVACCINATION
CRITICAL
WITNESSEDCONSENT &
VACCINATION
TESTING
CONTRAINDICATIONor DECLINE
TESTING
CONTRAIND.OR DECLINE
R
POST-EVENT
SAMPLE SAMPLE OUTPUT OF OUTPUT OF WEILL/CORNELL WEILL/CORNELL SMALLPOX SMALLPOX VACCINATION VACCINATION MODELMODEL
SAMPLE SAMPLE OUTPUT OF OUTPUT OF WEILL/CORNELL WEILL/CORNELL SMALLPOX SMALLPOX VACCINATION VACCINATION MODELMODEL
Predicted Length of Vaccination Campaign as a Function of Available Core Staff and Population Size
0
5
10
15
20
25
30
35
40
45
50
Available Core Staff
Day
s to
Vac
cin
ate
Pop=100K
Pop=500K
Pop=1MM
Pop=2.5MM
Pop=5MM
Pop=8MM
4 Days
13
57
911
1315
1719
2123
2527
29
12131415161718192021222324
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
Nu
mb
er
of
Pati
en
ts p
er
Day
Flow Rate (pt/min/POD)
Hours of Operation
Trend in Number of Patients Served by POD per Day of Vaccination Campaign as a Function of POD Flow Rate (pt/min/POD) and POD Hours of Operation*
*Assumes a campaign targetting 8MM people over 4 days
LimitationsLimitationsAccuracy of any model depends on the quality of Accuracy of any model depends on the quality of the underlying data the underlying data Processing times are critical variableProcessing times are critical variable
Output is design-specificOutput is design-specific A differently designed vaccination center may give a A differently designed vaccination center may give a
different resultdifferent result
Multiple scalable centers with externally Multiple scalable centers with externally controlled patient flowcontrolled patient flow Feasible but requires law enforcement inputFeasible but requires law enforcement input
These numbers reflect only critical dispensing These numbers reflect only critical dispensing staff and do not include support staff for the staff and do not include support staff for the centers or distribution and logistics staffcenters or distribution and logistics staff
ConclusionsConclusionsSpreadsheet modeling allows planners to “think Spreadsheet modeling allows planners to “think with numbers” when designing mass prophylaxis with numbers” when designing mass prophylaxis response strategiesresponse strategiesModeling forces critical examination of:Modeling forces critical examination of: Assumptions about vaccination center layout and Assumptions about vaccination center layout and
processesprocesses Availability of resourcesAvailability of resources
Model estimates are useful data to guide Model estimates are useful data to guide planning but do not replace the real thing: planning but do not replace the real thing: LIVE, REALISTIC EXERCISESLIVE, REALISTIC EXERCISES
AcknowledgmentsAcknowledgmentsCo-Investigators Co-Investigators Jason Cuomo, MPHJason Cuomo, MPH Mark A. Callahan, MDMark A. Callahan, MD Alvin I. Mushlin, MD, ScMAlvin I. Mushlin, MD, ScM
NYC Office of Emergency ManagementNYC Office of Emergency ManagementEdward Gabriel, MPA, AEMT-PEdward Gabriel, MPA, AEMT-PSam Benson, AEMT-PSam Benson, AEMT-PAnita Sher, MIAAnita Sher, MIA
U.S. DHHS, Office of the Asst. Sec’y for Public Health U.S. DHHS, Office of the Asst. Sec’y for Public Health PreparednessPreparednessCapt. Ann Knebel, RN, DNScCapt. Ann Knebel, RN, DNSc
NYC Dept. of Health, Communicable Disease UnitNYC Dept. of Health, Communicable Disease UnitMarci Layton, MDMarci Layton, MDSue Blank, MD, MPHSue Blank, MD, MPH
NY Presbyterian Healthcare SystemNY Presbyterian Healthcare SystemEliot Lazar, MDEliot Lazar, MDArthur Klein, MDArthur Klein, MDNeal Flomenbaum, MDNeal Flomenbaum, MD