emergency management strategies for identifying and integrating community resources to expand...
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Emergency Management Strategies for Identifying and Integrating Community
Resources to Expand Medical Surge Capacity:Alternate Care Facilities
Washington, DCFebruary 5, 2008
Stephen V. Cantrill, MDDepartment of Emergency Medicine
Denver Health Medical Center
The National Emergency Management Summit
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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 systemIntrinsic:
Facility basedCommunity based: Alternate Care Facilities
Extrinsic: State / Federal
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Community Based Surge Capacity
Requires close planning and cooperation amongst diverse groups who have traditionally not played togetherHospitalsOffices of Emergency ManagementRegional plannersState Department of Health
MMRS may be a good organizing force
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Where Have We Been?
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Hospital Reserve Disaster Inventory
Developed in 1950’s-1960’sDesigned to deal with trauma/nuclear
victimsDeveloped by US Dept of HEWHospital-based storage Included rotated pharmacy stock items
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Packaged Disaster Hospitals
Developed in 1950’s-1960’sDesigned to deal with trauma/nuclear victimsDeveloped by US Civil Defense Agency &
Dept of HEW2500 deployedModularized for 50, 100, 200 bed units45,000 pounds; 7500 cubic feet
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Packaged Disaster Hospitals
Last one assembled in 1962Adapted from Mobile Army Surgical
Hospital (MASH)Community or hospital-based storage
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Packaged Disaster Hospital: Multiple Units
Pharmacy Hospital supplies /
equipment Surgical supplies /
equipment IV solutions / supplies Dental supplies X-ray
Records/office supplies Water supplies Electrical
supplies/equipment Maintenance /
housekeeping supplies Limited oxygen
support
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Packaged Disaster Hospital
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Packaged Disaster Hospitals
Congress refused to supply funds needed to maintain them in 1972
Declared surplus in 1973Dismantled over the 1970’s-1980’sMany sold for $1
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The Re-Emergence of a Concept:The Alternate Care Facility
Planning Issues:Augmentation vs Alternate Facility?Physical space
Inclusion of actual structureTents, trailers, etcCost? Storage? Ownership?
Structure of opportunityPrivate vs Public sitesWho grants permission to use?Need for decon after use to restore to original function?
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Alternate Care Facility Planning Issues
It is not a miniature hospital“Ownership”, command and control?
HICS is a good starting structureWho decides to open the ACF?Scope & level of care to be delivered?
Offloaded hospital patientsPrimary victim careNursing home replacementAmbulatory chronic care / shelter
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ACF Planning Issues
StaffingMedical StaffAncillary Staff
Operational supportMealsSanitary needs InfrastructureSuppliesPharmaceuticals
Documentation of care Security
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ACF Planning Issues
CommunicationsHospitalsEMSEmergency Management: State/Local
Relations with EMSRules/policies for operationExit strategyExercising the plan
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Level I Cache:Hospital Augmentation
Bare-bones approachPhysical increase of 50 bedsWould rely heavily on hospital suppliesStored in a single trailer About $20,000 Within the realm of institutional ownershipReadily mobile - but needs vehicle
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Level I Cache:Hospital Augmentation
TrailerCotsLinens IV polesGlove, gowns, masksBP cuffsStethoscopes (Developed under AHRQ Task Order:
Rocky Mountain Regional Care Model for Bioterrorist Events)
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Used During Katrina Evacuee Relief
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Level II Cache: Regional Alternate Care Facility (ACF)
Significantly more robust in terms of supplies
Designed by one of our partners, Colorado Department of Public Health and Environment
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Level II Cache: Regional Alternate Care Facility Designed for initial support of 500 patients
Per HRSA recommendations of 500 patient surge per 1,000,000 population
Modular packaging for units of 50-100 pts
Regionally located and stored Trailer-based for mobility Has been implemented Approximate price less than $100,000 per copy
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Level II: Level I Plus:
Ambu bags Bed pans / Urinals Medical ID bracelets Chairs Cribs Emesis basins Forms for documentation IV sets Oxygen masks
Ice packs Pillows Privacy screens Soap Tables Duct tape Adhesive tape Thermometer strips Tongue depressors (Still No Drugs)
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Level III Cache:Comprehensive Alternate Care Facility
Adapted from work done by US Army Soldier and Biological Chemical Command
50 Patient modulesMost robust modelClosest to supporting non-disaster level of
care, but still limitedMore extensive equipment support
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Work at the Federal Level
DHHS: Public Health System Contingency StationSpecified and demonstrated250 beds in 50 bed unitsQuarantine or lower level of careFor use in existing structuresMultiple copies to be strategically placedOwned and operated by the federal government
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PHS-CSBase Support
WithQuarantine
PHS-CSTreatment
PHS-CSPharmaceutical
PHS-CSBed Aug
(50)
• Administration• Support• Feeding• Quarantine• Beds(50)• Housekeeping• First Aid Equipment• Pediatric Care• Adult Care• Personal Protective Equipment
• Primary Care• Non-Acute Treatment• Special Needs
• Pharmaceutical• Special Medications• Prophylaxis
• Beds• Bedding• Bedside Equipment
“PHS-CS” 250 Bed Module
Configuration
Basic Concept: HHS Public Health ServiceContingency Stations
(Federal Medical Stations)
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Station LayoutHall A
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upport
760 sq. ft.
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Possible Alternative Care Facilities
Hotel
Recreation Center
Church
Stadium
School
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ACF Site Selection
What is the best existing infrastructure/site in the region for delivering care?
(Developed under AHRQ Task Order:
Rocky Mountain Regional Care Model for Bioterrorist Events)
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FEDERAL Participants
US Northern Command
US Air Force
•Office of Surgeon General
•Homeland Security Office
•Development Center for
Operational Medicine
Colorado US Air Force, Army and
National Guard Bases
US Public Health Service-Region VIII
National Disaster Medical System (NDMS)
Department of Veteran Affairs
Medical Center
STATE Participants
Montana DPH
Colorado DPHE
Utah DPH
Wyoming DPH
North Dakota DPH
South Dakota DPH
Colorado Hospital Association
Colorado Rural Health Center
LOCAL Participants Tri- County Health Department
Denver County Health DepartmentJefferson County Health Department
Denver Mayor’s Office of Emergency ManagementThe Children’s Hospital of Denver
Exempla HealthcareDenver Health
HealthOneCentura Health
Kaiser PermanenteFront Range Metropolitan Medical Response System
Denver Center for Public Health Preparedness
Rocky Mountain Regional Care Model for Bioterrorist Events(RMBT) Working Group
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ACF Site Selection Tool
ACF infrastructure factors listed on one axis of a matrix.
Potential ACF sites listed on the other axis of the matrix.
Relative weight scale for each factor using a 5-point scale comparing factor to that of a hospital.
Developed as an Excel spreadsheet.
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Potential ACF Sites (pre-selected)
Aircraft hangers Churches Community/recreation
centers Convalescent care
facilities Fairgrounds Government buildings Hotels/motels Meeting Halls Military facilities
National Guard armories Same day surgical
centers/clinics Schools Sports Facilities/stadiums Trailers/tents
(military/other) Shuttered Hospitals Detention Facilities
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Factors to Weigh in Selection of an Alternate Care Facility Site
InfrastructureTotal Space and LayoutUtilitiesCommunicationOther Services
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Factors to Weigh in Selection of an Alternate Care Facility Site
InfrastructureDoor sizes FloorLoading DockParking for staff/visitorsRoofToilet facilities/showers (#)VentilationWalls
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Factors to Weigh in Selection of an Alternate Care Facility Site
Total Space and LayoutAuxiliary Spaces (Rx, counselors, chapel)Equipment/Supply storage areaFamily AreasFood supply/prep areaLab/specimen handling areaMortuary holding areaPatient decon areasPharmacy areasStaff areas
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Factors to Weigh in Selection of an Alternate Care Facility Site
UtilitiesAir conditioning Electrical power (backup)HeatingLightingRefrigerationWater
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Factors to Weigh in Selection of an Alternate Care Facility Site
CommunicationCommunication (# phones, local/long distance,
intercom)Two-way radio capabilityWired for IT and Internet Access
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Factors to Weigh in Selection of an Alternate Care Facility Site
Other ServicesAbility to lock down facilityAccessibility/proximity to public transportationBiohazard & other waste disposalLaundryOwnership/other uses during disasterOxygen delivery capabilityProximity to main hospitalSecurity personnel
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Weighted Scale5 = Equal to or same as a hospital.4 = Similar to that of a hospital, but has SOME
limitations (i.e. quantity/condition).3 = Similar to that of a hospital, but has some
MAJOR limitations (i.e. quantity/condition).2 = Not similar to that of a hospital, would take
modifications to provide.1 = Not similar to that of a hospital, would take
MAJOR modifications to provide.0 = Does not exist in this facility or is not
applicable to this event.
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Potential Non-Hospital Site Analysis Matrix
Ability to lock down facility
Adequate building security personnel
Adequate Lighting
Air Conditioning
Area for equipment storage
Biohazard & other waste disposalCommunications (# phones, Local/Long Distance, Intercom)Door sizes adequate for gurneys/beds
Electrical Power (Backup)
Family Areas
Floor & Walls
Food supply/food prep areas (size)
Heating
Lab/specimen handling area
Laundry
Loading Dock
Mortuary holding area
Oxygen delivery capability
Parking for staff/visitors
Patient decontamination areas
Pharmacy Area
Proximity to main hospital
Roof
Space for Auxillary Services (Rx, counselors, chapel)
Staff Areas
Toilet Facilities/Showers (#)
Two-way radio capability to main facility
Water
Wired for IT and Internet Access
Total Rating/Ranking (Largest # Indicates Best Site) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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Customizing the Site Selection Matrix
Additional relevant factors or facility sites can be added to the tool based on your area or the type of event.
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Issues to ConsiderIs each factor of equal weight?What if another use is already stated for
the building in a disaster situation? (i.e. a church may have a valuable community
role)
Are missing, critical elements able to be brought in easily to site?
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WHO needs this tool?
Incident commandersRegional plannersPlanning teams including: fire, law, Red
Cross, security, emergency managers, hospital personnel
Public works / hospital engineering should be involved to know what modifications are needed.
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WHEN should you use this tool?
Before an actual event.Choose best site for different scenarios so
have a site in mind for each “type”.
Available from: www.ahrq.gov/research/altsites.htm
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Who has used this tool?
Greece, in preparation for the OlympicsCaliforniaFloridaOther states/locations
Available from: www.ahrq.gov/research/altsites.htm
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The Supplemental Oxygen Dilemma
Supplemental oxygen need highly likely in a bioterrorism incident
Has been carefully researched by the Armed Forces Most options are quite expensive with high
cost/patient Many have very high power requirements Most require training/maintenance All present logistical challenges Remains an unresolved issue for civilian ACFs
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And Then The “Other” Problems:
Ventilators:Currently in US: 105,000In daily use: 100,000Projected pandemic need: 742,500
Respiratory Therapists
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Ventilators – Surge Supply
Additional full units - $32,000 eachSmaller units for $6,000 each
Many “Disposable” Units - $65 each
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Respiratory Therapists:Just-In-Time Training
MD
RT
Trainee TraineeTraineeTrainee
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
RT
Trainee Trainee Trainee
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Pt
Trainee
Pt
Pt
Pt
AHRQ: Project XTREME: www.ahrq.gov/prep/projxtreme/
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ACF Ideal Staffing: 33 Per 12 Hour Shift
Physician [1] Physician extenders
(PA/NP) [1] RNs or RNs/LPNs [6] Health technicians [4] Unit secretaries [2] Respiratory Therapists [1] Case Manager [1] Social Worker [1] Housekeepers [2] Lab [1]
Medical Asst/Phlebotomy [1] Food Service [2] Chaplain/Pastoral [1] Day care/Pet care Volunteers [4] Engineering/Maintenance
[.25] Biomed [.25] Security [2] Patient transporters [2]
MEMS ACC guidelines
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Emergency System for Advanced Registration of Volunteer Health Professionals:
ESAR-VHP
State-based registration, verification and credentialing of medical volunteers
Should allow easier sharing of volunteers across states
Still missing:Liability coverageCommand and control
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Medical Reserve Corps
Local medical volunteersNo corps unit uniform structure330 units of 55,000 volunteersDeployments do not qualify for FEMA
reimbursementLiability concerns are still an issueESAR-VHP may help with credentialing
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Development of Gubernatorial Draft Executive Orders
Developed by the Colorado Governor’s Expert Emergency Epidemic Response Committee (GEEERC)
Multi-disciplinary20 different specialties/fields (from attorney
general to veterinarians)To address pandemics or BT incidentsWork started in 2000
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Development of Gubernatorial Draft Executive Orders
Declaration of Bioterrorism/Pandemic Disaster Suspension of Federal Emergency Medical
Treatment and Active Labor Act (EMTALA) Allowing seizure of specific drugs from private
sources Suspension of certain Board of Pharmacy
regulations regarding dispensing of medication
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Development of Gubernatorial Draft Executive Orders
Suspension of certain physician and nurse licensure statutesAllows out-of-state or inactive license holders to
provide care under proper supervision
Allowing physician assistants and EMTs to provide care under the supervision of any licensed physician
Allowing isolation and quarantine Suspension of certain death and burial statutes
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Katrina: ACF Lessons Learned
Importance of regional planning Importance of security: uniforms are goodAdvantages of manpower proximitySegregating special needs populationsOrganized facility layout Importance of ICS
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Katrina: ACF Lessons Learned
The need for “House Rules” Importance of public health issues
Safe foodClean waterLatrine resourcesSanitation supplies
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Available from AHRQ:www.ahrq.gov/research/mce/mceguide.pdf
Contents: Ethical considerations Legal aspects Prehospital care Hospital/Acute care Alternative care sites Palliative care Pan-flu case study
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Disaster Alternate Care Facilities
Agency for Healthcare Research and Quality
Contract No. HHSA290200600020
Task Order No. 4
Review and Revise the Alternative Care Site Selection Tool
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Task Order
Review AARs and Lessons Observed from:Response to Hurricanes Katrina and Rita
- Sites such as Superdome, Convention Center
Use of Federal Medical StationsNDMS DMATsUse of other mobile assets
State experiences in site selection
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Task Order
Review, reconsider, revise site selection tool
Develop draft staffing and resource requirements for a full range of ACFs
Develop draft ACF conops
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SummaryWe are rediscovering some old conceptsSupplemental oxygen and respiratory support
remain problemsSurge staffing facilitation requires advance
planning at multiple levels and may still failDeveloping medical surge capacity requires close
planning and cooperation amongst diverse groups who have traditionally not played together