www.yalenewhavenhealth.org/emergency

Presentation to:

National Emergency Management Summit

March 6, 2007Yale New Haven Center for Emergency Preparedness and Disaster

Response

www.yalenewhavenhealth.org/emergency

Emergency Preparedness: Are Healthcare Systems Prepared for the New Normal?

James L. Paturas, CEM, EMTP, CHS-IVDeputy Director for Clinical Services

Identify the critical organizational elements that include management, clinical and technical expertise required to establish a regional resource center.

Outline the process involved in moving forward with the development of a regionally driven and fully integrated public health and healthcare delivery statewide plan for emergency preparedness

Identify the critical planning/research methods required to develop plans, polices and annexes that are replicable and transferable

OBJECTIVES

1950-2000

From 1951 through 2000 the number of disaster events increased by 1,100% from approximately 419 events from the years 1951-1960 to 5,512 from the years 1991-2000 according to the World Association for Disaster and Emergency Medicine (WADEM)

The number persons affected by disaster events increased by 18,000% from 11.5 million in the years from 1951-1960 to 2.1 billion for the years between 1991-2000 according to the World Association for Disaster and Emergency Medicine (WADEM)

And then came September 11, 2001

From 1951 through 2000 the number of disaster events increased by 1,100% from approximately 419 events from the years 1951-1960 to 5,512 from the years 1991-2000 according to the World Association for Disaster and Emergency Medicine (WADEM)

The number persons affected by disaster events increased by 18,000% from 11.5 million in the years from 1951-1960 to 2.1 billion for the years between 1991-2000 according to the World Association for Disaster and Emergency Medicine (WADEM)

And then came September 11, 2001

SEPTEMBER 2005

The nation was inadequately prepared to continue normal operations in the face of the enormity of the disaster caused byHurricanes Katrina and Rita, which destroyed or disabled hospital buildings, transportation and other vital infrastructure in addition to generating large numbers of patients to treat

Public safety individuals and organizations were not prepared tointegrate their normal functions with those of hospital systems and healthcare delivery organizations to manage the surge of patients.

Communities delegated preparedness responsibility to individual institutions but had not planned for the possibility of an event that would affect multiple institutions and support agencies simultaneously.

Counties and states did not have experience working together, had not planned together adequately and were not organized to respond to a major disruption of hospital services and medical surge event.

Resources were unavailable when needed or unable to be used as effectively as if they had been mobilized in a unified, integrated response.

The nation was inadequately prepared to continue normal operations in the face of the enormity of the disaster caused byHurricanes Katrina and Rita, which destroyed or disabled hospital buildings, transportation and other vital infrastructure in addition to generating large numbers of patients to treat

Public safety individuals and organizations were not prepared tointegrate their normal functions with those of hospital systems and healthcare delivery organizations to manage the surge of patients.

Communities delegated preparedness responsibility to individual institutions but had not planned for the possibility of an event that would affect multiple institutions and support agencies simultaneously.

Counties and states did not have experience working together, had not planned together adequately and were not organized to respond to a major disruption of hospital services and medical surge event.

Resources were unavailable when needed or unable to be used as effectively as if they had been mobilized in a unified, integrated response.

Are Healthcare Systems Prepared for the New Normal

Largest, most integrated healthcare system in Connecticut12,000 employees and 3,500 physicians78,000 patient discharges and 1,300,000 outpatient visits3 acute care hospitals, a children’s hospital and a psychiatric hospital− A Level 1 Burn Center and one Level 1 Trauma Centers

Primary teaching hospital of the Yale University School of Medicine (YSM)

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Bridgeport Greenwich Yale-New Haven

Westerly YSM

Our Mission“To develop and deliver services around the nation and internationally that advance healthcare planning, preparedness and response for emergency events and disasters through collaborative partnerships and coordinated programs.”

Yale New Haven Center for Emergency Preparednessand Disaster Response

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Yale New Haven Center for Emergency Preparedness and Disaster Response

Designated by the Commissioner of the Department of Public Health (DPH) in 2002 as a Center of Excellence (CoE) for Bioterrorism Preparedness and Response in Connecticut

At the request of the Connecticut Department of Public Health, Yale New Haven Health System (YNHHS) was charged with developing statewide emergency preparedness programs and education and training services for healthcare delivery organizations

Yale New Haven Center for Emergency Preparedness and Disaster Response

Provides leadership to:− 32 Acute Care Hospitals

− 90 Emergency Medical Services Agencies

− 41 Community Health Centers

− 66 Home Health Agencies

− 22 Urgent Care Centers

− 106 Skilled Nursing Facilities

− 7,000 Community Medical Practitioners

In addition, partnerships have been developed between the YNHHS CoE and the following organizations:− Mental Health Community

− Local Public Health/Public Safety

− Other Agencies (transportation, pharmacies, medical supply distributors, etc.)

Designated by the Centers for Disease Control and Prevention (CDC) as the Connecticut Center for Public Health Preparedness (CPHP) at YNHHS

The only hospital system in the country with a CDC CPHP designation

The Yale New Haven Health System Center of Excellence for Bioterrorism Preparedness and Response and the Yale University School of Medicine have developed a collaborative relationship in the following academic, clinical and support areas:− Emergency/Disaster Medicine− Public Health− Epidemiology− Infectious Disease− Toxicology− Burn/Trauma Surgery− Radiation Health/Nuclear Medicine− Pediatrics− Mental Health− Occupational/Environmental Health− Web Design and Development− Learning Management Systems− Emergency Response Resource Database

This academic/clinical relationship has fostered an environment that includes academic research, applied medicine and clinical education

The Yale New Haven Health System Center of Excellence for Bioterrorism Preparedness and Response and the Yale University School of Medicine have developed a collaborative relationship in the following academic, clinical and support areas:−− Emergency/Disaster Medicine− Public Health− Epidemiology− Infectious Disease− Toxicology− Burn/Trauma Surgery− Radiation Health/Nuclear Medicine− Pediatrics− Mental Health−− Occupational/Environmental Health− Web Design and Development− Learning Management Systems− Emergency Response Resource Database

This academic/clinical relationship has fostered an environment that includes academic research, applied medicine and clinical education

Academic/Clinical Delivery Partnership

Public Safety Organizations

Governmental Organizations

Public Health Organizations

Healthcare Delivery Organizations

TransportationOrganizations

Private Sector Organizations

Utility CompanyOrganizations

Statewide Response Organizations

Horizontal and Vertical Integration for Emergency Response

Local Response Organizations

Federal Response Organizations

Federal Organizations(HHS, DHS, FEMA, DoD)

Statewide Public Safety Organizations

Statewide Governmental Organizations

Statewide Healthcare

Organizations

Integration of Response Systems

First PreparersGeneral PopulationPrivate IndustryCity PlannersDisaster PlannersNational PlannersPublic Health

First RespondersPoliceFireEMSCity and County Health OfficialsPublic Health

First ReceiversHospitalsClinicsHealth FacilitiesMedical Providers

Transportation, security, infrastructure,

crisis communications

FP

Healthcare delivery focused

Manmade/ natural events

Basic Disaster Life Support (BDLS)Advanced Disaster Life Support (ADLS)Pre-hospital Trauma Life Support (PHTLS)

FRd

FR

PersonnelBedsEquipmentPharmaceuticals/Medical SuppliesFacilities/SecurityCommunication Systems and Processes

Building a Healthcare Surge Capacity

Surge Capacity Determinants

Critical Capacity Evaluation Summary

Alternate Healthcare Delivery During a Pandemic Scenario

ICU

Acute Care Hospital

Critical Non-Critical

Triage

Alternate Care Sites–Traditional

Occupational Medical Services

Occupational Medical Services

Nursing HomesNursing Homes

Rehab HospitalsRehab Hospitals

Schools of Nursing/

Other Health Professions

Schools of Nursing/

Other Health Professions

Community Health Centers

Community Health Centers

Community Medical Practices

Community Medical Practices

Home Health Agencies

Home Health Agencies

School Based Health AgenciesSchool Based

Health Agencies

Mobile Medical Clinics

Mobile Medical Clinics

University Health Services

University Health Services

Urgent CareUrgent Care

Civic CentersCivic Centers HouseholdsHouseholds

HotelsHotels Senior CentersSenior Centers

Non-Traditional

Regional Healthcare Contingency Delivery Centers (RHCDC)

A National Model

RHCDC MISSION

To supplement the existing national health care infrastructure by dedicating surge resources for coordination of health care delivery, education, research and integrated community services.

Responsible for the coordinated development, implementation, evaluation of training, and capacities (such as administrative support, infrastructure including healthcare epidemiology, laboratories, information systems, leadership and expert personnel, research capability, equipment and supplies) for the healthcare delivery and response community within a defined geographic area

To supplement the existing national health care infrastructure by dedicating surge resources for coordination of health care delivery, education, research and integrated community services.

Responsible for the coordinated development, implementation, evaluation of training, and capacities (such as administrative support, infrastructure including healthcare epidemiology, laboratories, information systems, leadership and expert personnel, research capability, equipment and supplies) for the healthcare delivery and response community within a defined geographic area

First Responders

- Primary Care Providers

- Emergency Dept.Staff

- Public Health Professionals

- Local Laboratories

Public Health (PH) Depts.

Local EOCs

Military Installation PH Officers

State Health Depts.

Other State assets

State EOCs

National Guard

Emergency Coordinators in Regions

Federal Coordinating Officers

Disease investigation teams

Vaccination Teams

National Lab services

Data analysis support

Strategic National Stockpile

NDMS teams

- DMAT, NMRT, DMORT, DVAT

Other NDMS support

- Hospitalization (VA and DOD)

- DOD Advisory teams

- DOD augmentation teams

- DOD lab and technical support

- DOD general logistics (food, water, electricity, shelter)

- DOD transportation

DOD support to law enforcement

DOD general logistics (food, water, electricity, shelter)

- DOD transportation

State Response

MMRS

Local Response, Municipal and County

Min

im

al

Low

Med

ium

Hig

h

Sev

ere

IInfluenza, foodborne

illnesses, endemic plague

Anthrax, plague with 1-2 cases Pandemic influenzaSmallpox Bioengineered agent

Severity

Time

Federal Response

Integrated Medical Capabilities: Red Wedge of Response

RHCDC COMPONENTS

RHCDC

Regional Healthcare Contingency Delivery Center Organizational Model

Regional Healthcare Regional Healthcare Contingency Delivery Contingency Delivery

CenterCenter

FacilitiesFacilities Supplies / Supplies / PharmaceuticalsPharmaceuticals

PersonnelPersonnel EquipmentEquipment

Federal Medical Contingency Station

Military Assets (i.e. EMeds)

Strategic National Strategic National StockpileStockpile

State Assets (i.e. MaSH)

Local Assets (Hospitals)

Chempack Chempack

Regional Shared Regional Shared Cache StockpileCache Stockpile

Facility Cache Facility Cache StockpileStockpile

ESAR-VIP

State Emergency Credentialing

Programs

Military / Federal Personnel

Medical Reserve Corps (MRC)

Inpatient / Outpatient Beds

Ventilators, isolation units,

Decon Units

Regional Shared Regional Shared Equipment CacheEquipment Cache

Facility Equipment Facility Equipment Cache Cache

RHCDC PROGRAM DEFINITIONS

Facilities – Develop a model for facility surge capacity for the provision of medical care in response to a disaster

Consider alternative treatment sites and transport, access and security activities

Utilize non-traditional treatment/patient care areas

Predetermine triage locations (on-site or off-site) including primary and secondary triage locations

Define, identify and equip patient care capacity at off-site facilities

Establish policies on integration of Federal, State and non-government facility resources

Establish emergency (temporary) identification protocols

Enhance protection of critical infrastructure

Facilities – Develop a model for facility surge capacity for the provision of medical care in response to a disaster

Consider alternative treatment sites and transport, access and security activities

Utilize non-traditional treatment/patient care areas

Predetermine triage locations (on-site or off-site) including primary and secondary triage locations

Define, identify and equip patient care capacity at off-site facilities

Establish policies on integration of Federal, State and non-government facility resources

Establish emergency (temporary) identification protocols

Enhance protection of critical infrastructure

RHCDC PROGRAM DEFINITIONS

Personnel – Establish regional and national medical healthcare personnel response capability integrated with state and federal response programs

Integrate Federal and State government resources (e.g. DMATs, Public Health Service, VA System, National Guard)

Mutual aid agreements with surrounding area hospitals.

Use emergency credentialing systems that include a process for verification of credentials

Investigate each states licensing/certification verification systems for all relevant staff types.

Investigate the existence of agreements between neighboring states for waiving license verification in a disaster situation.

Personnel – Establish regional and national medical healthcare personnel response capability integrated with state and federal response programs

Integrate Federal and State government resources (e.g. DMATs, Public Health Service, VA System, National Guard)

Mutual aid agreements with surrounding area hospitals.

Use emergency credentialing systems that include a process for verification of credentials

Investigate each states licensing/certification verification systems for all relevant staff types.

Investigate the existence of agreements between neighboring states for waiving license verification in a disaster situation.

Education, Research and Evaluation – Provide coordinated and consistent education and training programs that support state and federal mandates Train and exercise clinical, operations and facility personnel to fulfill their disaster medicine response roles

Education and training courses centered on mass casualty disaster response and will include continued refinement of:

– Clinical and operating policies and procedures– Hospital Incident Command System (HICS)– Transporting, deploying and restaging the facility– Communication– Maintenance and use of equipment

Education and training programs will combine clinical mentoring, programs and procedures and printed resources along with hands-on equipment training and facility preparations.

Education, Research and Evaluation – Provide coordinated and consistent education and training programs that support state and federal mandates Train and exercise clinical, operations and facility personnel to fulfill their disaster medicine response roles

Education and training courses centered on mass casualty disaster response and will include continued refinement of:

– Clinical and operating policies and procedures– Hospital Incident Command System (HICS)– Transporting, deploying and restaging the facility– Communication– Maintenance and use of equipment

Education and training programs will combine clinical mentoring, programs and procedures and printed resources along with hands-on equipment training and facility preparations.

RHCDC PROGRAM DEFINITIONS

Supplies/Pharmaceuticals – Provide a consistent approach to availability of regional supply stockpiling for up to 72 hours prior to arrival of the SNS

Identify and inventory existing caches of pharmaceuticals, equipment and medical supplies that are available locally, regionally and at the state level.

Develop comprehensive plans that establish integration and coordination with any other state, regional or federal assets that may become available.

Collaborate with local and regional partners to establish caches of equipment and the development of coordinated supply and pharmaceutical stockpile agreements

Establish appropriate communication and requisition processes that ensure ongoing supplies and pharmaceuticals access and support

Supplies/Pharmaceuticals – Provide a consistent approach to availability of regional supply stockpiling for up to 72 hours prior to arrival of the SNS

Identify and inventory existing caches of pharmaceuticals, equipment and medical supplies that are available locally, regionally and at the state level.

Develop comprehensive plans that establish integration and coordination with any other state, regional or federal assets that may become available.

Collaborate with local and regional partners to establish caches of equipment and the development of coordinated supply and pharmaceutical stockpile agreements

Establish appropriate communication and requisition processes that ensure ongoing supplies and pharmaceuticals access and support

RHCDC PROGRAM DEFINITIONS

Equipment – develop a standard approach and process for available equipment to meet medical surge capacity of patients in a given region and a model for equipment stockpiling across the nation

Employ an all hazards / multi-use approach to determine equipment stockpile plans based on most likely threats/events

Identify medical equipment from state, local and federal agencies that include environmental, engineering and biomedical equipment

Determine financing of equipment acquisition, outsourcing needs and identify partnering companies.

Conduct evaluation of total par level recommendations and general availability at each RHCDC

Integrate RHCDC facility specific plans with local, regional and statewide initiatives

Equipment – develop a standard approach and process for available equipment to meet medical surge capacity of patients in a given region and a model for equipment stockpiling across the nation

Employ an all hazards / multi-use approach to determine equipment stockpile plans based on most likely threats/events

Identify medical equipment from state, local and federal agencies that include environmental, engineering and biomedical equipment

Determine financing of equipment acquisition, outsourcing needs and identify partnering companies.

Conduct evaluation of total par level recommendations and general availability at each RHCDC

Integrate RHCDC facility specific plans with local, regional and statewide initiatives

RHCDC PROGRAM DEFINITIONS

Communications – Develop integrated and consistent approaches to communication processes and equipment for the delivery of medical care locally, regionally and nationally and through horizontal and vertical integration

Develop consensus across the various partners that coordinates state intergovernmental communications response activities

Public health emergency communication plans linked with local government, private healthcare agencies, professional associations and private industry

Public health and healthcare partners develop specific tactical emergency communications plans to support a public health response for detection, surveillance, diagnostic and clinical management, emergency notification, voice communication and supporting technologies

Establish and prioritize cost effective emergency communications and information technology standards for the purchase of hardware and software that supports interoperability and redundancy

Communications – Develop integrated and consistent approaches to communication processes and equipment for the delivery of medical care locally, regionally and nationally and through horizontal and vertical integration

Develop consensus across the various partners that coordinates state intergovernmental communications response activities

Public health emergency communication plans linked with local government, private healthcare agencies, professional associations and private industry

Public health and healthcare partners develop specific tactical emergency communications plans to support a public health response for detection, surveillance, diagnostic and clinical management, emergency notification, voice communication and supporting technologies

Establish and prioritize cost effective emergency communications and information technology standards for the purchase of hardware and software that supports interoperability and redundancy

RHCDC PROGRAM DEFINITIONS

INTEGRATION

PRE-EVENT INTEGRATION

RHCDC will provide for an integrated and comprehensive program and response components within a defined geographic area and representing an effected or at-risk population and shall:

During the pre-event phase, develop, test (through exercises), and have in place plans for clinical services delivery

During the pre-event phase, prepare, test, and have in place plans to develop new, and to maintain existing, collaborations with members of the healthcare delivery and response community

RHCDC will provide for an integrated and comprehensive program and response components within a defined geographic area and representing an effected or at-risk population and shall:

During the pre-event phase, develop, test (through exercises), and have in place plans for clinical services delivery

During the pre-event phase, prepare, test, and have in place plans to develop new, and to maintain existing, collaborations with members of the healthcare delivery and response community

EVENT INTEGRATION

During the event phase, deliver clinical services to affected and at risk populations and provide medical management and treatment of adverse events arising from utilization of clinical services developed in response to an emer-gency situation

During the event phase, communicate preliminary findings regarding the delivery and efficacy of clinical services to appropriate Federal, State, and local public health authorities

During the event phase, deliver clinical services to affected and at risk populations and provide medical management and treatment of adverse events arising from utilization of clinical services developed in response to an emer-gency situation

During the event phase, communicate preliminary findings regarding the delivery and efficacy of clinical services to appropriate Federal, State, and local public health authorities

POST EVENT INTEGRATION

During the post event phase, have in place a validated process of metrics and measures for eval-uating the effectiveness of clinical services through clinical research, including external evalua-tion, quality assurance and mitigation, and an eval-uation of the clinical services delivery center’s capability to respond to the needs of populations at risk and address potential hazard vulnerabilities

During the post-even phase, share information about the effectiveness of services and the capability of the RHCDC delivery centers to respond to the event to appropriate Federal, State, military and local public health authorities

During the post event phase, have in place a validated process of metrics and measures for eval-uating the effectiveness of clinical services through clinical research, including external evalua-tion, quality assurance and mitigation, and an eval-uation of the clinical services delivery center’s capability to respond to the needs of populations at risk and address potential hazard vulnerabilities

During the post-even phase, share information about the effectiveness of services and the capability of the RHCDC delivery centers to respond to the event to appropriate Federal, State, military and local public health authorities

SUMMARY

James L. PaturasDeputy Director, YNH-CEPDR

James.paturas@ynhh.org

One Church Street, New Haven, CT 06510www.yalenewhavenhealth.org/emergency

James L. PaturasDeputy Director, YNH-CEPDR

James.paturas@ynhh.org

One Church Street, New Haven, CT 06510www.yalenewhavenhealth.org/emergency

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