Healthcare Surge Healthcare Surge Capacity in Capacity in DisastersDisasters

Adapted from a presentation by Adapted from a presentation by John L. Hick, MD. Used with John L. Hick, MD. Used with permissionpermission

Barbara Barbara DodgeDodgeVirginia Virginia HelgetHelgetSharon Sharon MedcalfMedcalf

OverviewOverview Section 1 – Incidents and Incident Section 1 – Incidents and Incident

ManagementManagement

Section 2 – Healthcare Facility and Section 2 – Healthcare Facility and Community Surge Community Surge

Section 3 – Selected Surge Section 3 – Selected Surge Situations and Special TopicsSituations and Special Topics

Section 1: Section 1: Incidents and Incidents and Incident Incident ManagementManagement

OverviewOverview

Define disasterDefine disaster Incident management and its Incident management and its

importance in surge capacityimportance in surge capacity The CST of surgeThe CST of surge Getting all C’s – Command, control, Getting all C’s – Command, control,

communications and coordinationcommunications and coordination

What is a disaster?What is a disaster? Demand for resources acutely Demand for resources acutely

outstrips supplyoutstrips supply May depend on day / time / facilityMay depend on day / time / facility Internal / External eventsInternal / External events Static vs. dynamic - timelineStatic vs. dynamic - timeline

Contagious events special sub-categoryContagious events special sub-category ‘‘Complex Incidents’Complex Incidents’

Key goal of planning and Key goal of planning and incident management:incident management:

Get the…Get the… RightRight resourcesresources…to the…to the RightRight placeplace…at the…at the RightRight timetime…to prevent…to prevent A ‘special incident’ from becoming A ‘special incident’ from becoming

a…a…

DISASTERDISASTER

Disasters – Reality Disasters – Reality CheckCheck Only 7 disasters in U.S. history have Only 7 disasters in U.S. history have

resulted in > 1000 fatalitiesresulted in > 1000 fatalities Only 10-15 incidents per year result Only 10-15 incidents per year result

in more than 40 injured victimsin more than 40 injured victims

Historic DisastersHistoric Disasters

1865 Steamship explosion1865 Steamship explosion 1,547 deaths1,547 deaths 1871 Peshtigo, WI fire1871 Peshtigo, WI fire 1,1821,182 1889 Jonestown, PA flood 1889 Jonestown, PA flood > 2,200 > 2,200 1904 Steamship fire, NYC 1904 Steamship fire, NYC 1,0211,021 1928 FL Okeechobee Hurricane 2,0001928 FL Okeechobee Hurricane 2,000 2001 NYC WTC disaster2001 NYC WTC disaster 2,795 2,795

(inexact)(inexact) 2005 Hurricane Katrina 2005 Hurricane Katrina 1697 1697

(inexact)(inexact)

Cap

ab

ilit

ies

and

Res

ou

rces

Federal Response

Regional / Mutual Response Systems

State Response

Increasing magnitude and severity

Local Response, Municipal and County

Tiered Response StrategyTiered Response Strategy

Minimal Low Medium High Catastrophic

Now, Now,

let’s think about let’s think about

PlanningPlanning

What is most likely?What is most likely?

Moderate sized disasterModerate sized disaster > 120 injured is threshold for chaos> 120 injured is threshold for chaos Plan for 50-150 victims Plan for 50-150 victims Tie planning to Hazard Vulnerability Tie planning to Hazard Vulnerability

AnalysisAnalysis

Planning DocumentsPlanning Documents

Hazard Vulnerability Hazard Vulnerability AnalysisAnalysis

Emergency Management Emergency Management PlanPlan

Emergency Operations PlanEmergency Operations Plan Departmental PlansDepartmental Plans

CHRISTUS Spohn Hospital South

HAZARD AND VULNERABILITY ASSESSMENT TOOLEVENTS INVOLVING HAZARDOUS MATERIALS

SEVERITY = (MAGNITUDE - MITIGATION)

EVENTPROBABILITY HUMAN

IMPACTPROPERTY

IMPACTBUSINESS

IMPACTPREPARED-

NESSINTERNAL

RESPONSEEXTERNAL RESPONSE

RISK

Likelihood this will occur

Possibility of death or injury

Physical losses and damages

Interuption of services

PreplanningTime,

effectivness, resouces

Community/ Mutual Aid staff

and suppliesRelative threat*

SCORE

0 = N/A 1 = Low 2 = Moderate 3 = High

0 = N/A 1 = Low 2 = Moderate 3 = High

0 = N/A 1 = Low 2 = Moderate 3 = High

0 = N/A 1 = Low 2 = Moderate 3 = High

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 - 100%

Mass Casualty Hazmat Incident (From historic events at your MC with >= 5 victims)

1 2 1 2 1 2 1 17%

Small Casualty Hazmat Incident (From historic events at your MC with < 5 victims)

2 2 1 2 1 1 1 30%

Chemical Exposure, External

1 2 1 1 1 1 1 13%

Small-Medium Sized Internal Spill

1 1 1 1 2 2 1 15%

Large Internal Spill 1 1 1 1 2 2 1 15%

Terrorism, Chemical2 2 1 2 1 1 1 30%

Radiologic Exposure, Internal

1 1 1 1 2 2 2 17%

Radiologic Exposure, External

1 1 1 1 2 2 1 15%

Terrorism, Radiologic

1 1 1 1 2 2 1 15%

AVERAGE 1.22 1.44 1.00 1.33 1.56 1.67 1.11 18%

*Threat increases with percentage.

11RISK = PROBABILITY * SEVERITY

73 0.18 0.41 0.45

What is Surge What is Surge Capacity?Capacity?

Surge Capacity C S TSurge Capacity C S T

The 4 C’sThe 4 C’s CommandCommand ControlControl CommunicationCommunication

ss CoordinationCoordination

* Surge capacity * Surge capacity CANNOT occur if CANNOT occur if you don’t ‘get all you don’t ‘get all C’s’C’s’

The 4 S’sThe 4 S’s SpaceSpace StaffStaff StuffStuff SpecialSpecial

The 3 T’sThe 3 T’s TriageTriage TreatTreat TransportTransport

CommandCommand

What is Incident Command?What is Incident Command? Incident Management SystemIncident Management System Multi-agency Coordination SystemMulti-agency Coordination System Public Information SystemsPublic Information Systems

Standard languageStandard language Standardized job dutiesStandardized job duties Scalable and flexibleScalable and flexible

Basic HICS Basic HICS StructureStructure

INCIDENT COMMANDER

LIAISONOFFICER

SAFETY OFFICER

PUBLIC INFORMATIONOFFICER

LOGISTICSSECTION

PLANNINGSECTION

FINANCESECTION

OPERATIONSSECTION

MEDICAL TECHNICALSPECIALIST

Tools in the new HICSTools in the new HICS

Job action sheetsJob action sheets Position recommendationsPosition recommendations Incident Planning GuidesIncident Planning Guides Incident Response GuidesIncident Response Guides Forms – consistent with FEMA Forms – consistent with FEMA

requirementsrequirements NIMS (compliance activities)NIMS (compliance activities)

Use it oftenUse it often Incident Command must be used Incident Command must be used

as frequently as possible (daily as frequently as possible (daily responses)responses)

Employee familiarity and comfort Employee familiarity and comfort with system is dependent on with system is dependent on exposure / practiceexposure / practice

Surge Capacity PartnersSurge Capacity Partners EMS EMS Emergency ManagementEmergency Management Public HealthPublic Health Public Safety/Law enforcementPublic Safety/Law enforcement Hospitals and Healthcare SystemsHospitals and Healthcare Systems American Red CrossAmerican Red Cross Behavioral healthBehavioral health Jurisdictional legal authoritiesJurisdictional legal authorities

Regional CoordinationRegional Coordination

Medical Response SystemsMedical Response Systems Trauma SystemTrauma System Public Health DistrictsPublic Health Districts Regional Hospital Resource Center Regional Hospital Resource Center

(RHRC)(RHRC) Multi-Agency CoordinationMulti-Agency Coordination

Federal AssetsFederal Assets

National Disaster Medical System National Disaster Medical System (NDMS)(NDMS)

Urban Search and Rescue (eg: Urban Search and Rescue (eg: Nebraska TF-1)Nebraska TF-1)

Commissioned Corps Readiness Commissioned Corps Readiness ForceForce

Military (NORTHCOM)Military (NORTHCOM) Federal Medical StationsFederal Medical Stations CDC SNS and VMICDC SNS and VMI

Section 2: Section 2: Healthcare Facility Healthcare Facility and Community and Community Surge Surge

OverviewOverview

Initial ActionsInitial Actions Facility-based surgeFacility-based surge

Space, staff, stuff, specialSpace, staff, stuff, special Triage, treatment, and transportTriage, treatment, and transport

Community-based surge capacityCommunity-based surge capacity Partners and playersPartners and players Alternate care sitesAlternate care sites

Capacity vs. CapabilityCapacity vs. Capability

Surge Capacity – ‘the ability to manage Surge Capacity – ‘the ability to manage increased patient care volume that increased patient care volume that otherwise would severely challenge or otherwise would severely challenge or exceed the existing medical infrastructure’exceed the existing medical infrastructure’

Surge Capability – ‘the ability to manage Surge Capability – ‘the ability to manage patients requiring unusual or very patients requiring unusual or very specialized medical evaluation and specialized medical evaluation and intervention, often for uncommon medical intervention, often for uncommon medical conditions’conditions’

Barbera and MacintyreBarbera and Macintyre

Initial Actions – Notification Initial Actions – Notification and Communicationand Communication Facility notified of event / recognizes eventFacility notified of event / recognizes event

AdvisoryAdvisory AlertAlert

Declaring an emergency – Declaring an emergency – ActivationActivation

Mobilize adequate resources based on intelMobilize adequate resources based on intel Plan for next operational period (action planning cycles)Plan for next operational period (action planning cycles)

Notifying Notifying StaffStaff Patients and their familiesPatients and their families General publicGeneral public

Ongoing communications / information cycleOngoing communications / information cycle

Different types of ‘surge’Different types of ‘surge’

Pre-event surge (eg: pandemic, Pre-event surge (eg: pandemic, hurricane)hurricane)

Healthcare facility-basedHealthcare facility-based DischargesDischarges AdmissionsAdmissions

Community-basedCommunity-based Ambulatory careAmbulatory care

Existing sitesExisting sites Field treatment sitesField treatment sites

Non-ambulatory care (acute care center / Non-ambulatory care (acute care center / off-site)off-site)

EMSEMS

Pre-event surge /actionsPre-event surge /actions

If short warning time present:If short warning time present: Determine what service lines will be Determine what service lines will be

maintainedmaintained Mobilize staff and resourcesMobilize staff and resources

If longer warning time:If longer warning time: Consider expanding services to take Consider expanding services to take

care of as much elective business as care of as much elective business as possible (eg; evening operative cases, possible (eg; evening operative cases, expanded clinic hours)expanded clinic hours)

Facility-based SurgeFacility-based Surge

Hospitals may use HRSA dollars to Hospitals may use HRSA dollars to purchase cots, lab equipment, and purchase cots, lab equipment, and other supplies other supplies

Nearly always preferred to off-siteNearly always preferred to off-site Comfort of staffComfort of staff ExpertiseExpertise

Off-site: designate what equipment Off-site: designate what equipment can be taken and who can operate can be taken and who can operate itit

Reality CheckReality Check

Very rare to be overwhelmed in a Very rare to be overwhelmed in a disasterdisaster

Only 6% of hospitals in 29 Only 6% of hospitals in 29 disasters experienced supply disasters experienced supply issues, and 2% had staffing issues, and 2% had staffing shortages . . . shortages . . .

Most had too many!Most had too many!

In the Real World . . .In the Real World . . .

At least 50% arrive self-referredAt least 50% arrive self-referred ‘‘Upside down triage’ – least Upside down triage’ – least

wounded arrive firstwounded arrive first On average, 67% of patients in any On average, 67% of patients in any

given disaster are cared for at the given disaster are cared for at the hospital nearest the event (range 41-hospital nearest the event (range 41-97%)97%)

Rule of ThumbRule of Thumb Per 100 patients injured:Per 100 patients injured:

25 dead at scene25 dead at scene 75 seek medical care75 seek medical care

63 minor63 minor 12 serious12 serious

‘‘Rule of 85/15%’ has applied to all Rule of 85/15%’ has applied to all disasters thus far inc NYC 9-11 disasters thus far inc NYC 9-11 (minor vs. serious)(minor vs. serious)

In every catastrophic disaster, In every catastrophic disaster, sustained pressure on the healthcare sustained pressure on the healthcare system is seen following the incidentsystem is seen following the incident

Critical Hospital Critical Hospital ResourcesResources Physical PlantPhysical Plant PersonnelPersonnel SupervisionSupervision Supplies and EquipmentSupplies and Equipment CommunicationCommunication TransportationTransportation

Koenig K et al. Acad Emerg Med 1996:3;723-Koenig K et al. Acad Emerg Med 1996:3;723-77

Surge Capacity C S TSurge Capacity C S T

The 4 C’sThe 4 C’s CommandCommand ControlControl CommunicationCommunication

ss CoordinationCoordination

* Surge capacity * Surge capacity CANNOT occur if CANNOT occur if you don’t ‘get all you don’t ‘get all C’s’C’s’

The 4 S’sThe 4 S’s SpaceSpace StaffStaff StuffStuff SpecialSpecial

The 3 T’sThe 3 T’s TriageTriage TreatTreat TransportTransport

SpaceSpace ED and clinic triage protocols (evolve with event)ED and clinic triage protocols (evolve with event) Discharges and transfers (eg: nursing home)Discharges and transfers (eg: nursing home)

Discharge holding areaDischarge holding area Treat patients in halls / flat space areas (cots)Treat patients in halls / flat space areas (cots) Cancel elective proceduresCancel elective procedures Convert procedure/OR/PACU areas to ICU spaceConvert procedure/OR/PACU areas to ICU space Accommodate vents on floor Accommodate vents on floor Alternative ambulatory care areas / triage areasAlternative ambulatory care areas / triage areas

SpaceSpace Don’t forget surge space for:Don’t forget surge space for:

Family members / Family support centerFamily members / Family support center Tracking system (badge)Tracking system (badge)

Media in separate spaceMedia in separate space Consider traffic patterns and satellite spaceConsider traffic patterns and satellite space

Behavioral health areaBehavioral health area Staff respiteStaff respite Labor poolLabor pool Staff housing / sleeping (family Staff housing / sleeping (family

members?)members?)

StaffStaff Different events = different staff Different events = different staff

needsneeds Eg: HAZMAT vs. trauma vs. Eg: HAZMAT vs. trauma vs.

monkeypoxmonkeypox Appropriate specialtiesAppropriate specialties

Scope of event = scope of staff call-inScope of event = scope of staff call-in Mechanism to reach staffMechanism to reach staff Obligations of the staffObligations of the staff

Contract staffContract staff What are they required to do?What are they required to do?

StaffStaff Assign staff to specific areas when Assign staff to specific areas when

possiblepossible Don’t forget the support staff Don’t forget the support staff Nursing staff often limiting factorNursing staff often limiting factor

Team nursingTeam nursing Involve family in careInvolve family in care

What do specialists “have” to do?What do specialists “have” to do? Staff extenders / Staff rolesStaff extenders / Staff roles

Mentoring and supervision of extra staffMentoring and supervision of extra staff Just in time trainingJust in time training

Staff AugmentationStaff Augmentation Hospital personnelHospital personnel Clinic personnelClinic personnel Medical Reserve CorpsMedical Reserve Corps Non-clinical practice professionalsNon-clinical practice professionals Retired professionals (eg: via Retired professionals (eg: via

Medical Society)Medical Society) Trainees in health professionsTrainees in health professions Civil Support Team, Civil Air PatrolCivil Support Team, Civil Air Patrol Lay public (CERT teams, etc)Lay public (CERT teams, etc) Federal / interstate personnelFederal / interstate personnel

StuffStuff

Provider protectionProvider protection General patient care suppliesGeneral patient care supplies Specialty patient care suppliesSpecialty patient care supplies Support suppliesSupport supplies

Stuff – Provider Stuff – Provider ProtectionProtection Personal Protective EquipmentPersonal Protective Equipment Medications – antidotes?, anti-virals?Medications – antidotes?, anti-virals? Consider:Consider:

re-usere-use duration of useduration of use other risk-reducing strategies (UV light, other risk-reducing strategies (UV light,

ventilation, etc)ventilation, etc)

Stuff – General Patient Stuff – General Patient CareCare Airway – disposable intubation blades, Airway – disposable intubation blades,

bag/masksbag/masks Surgical – chest tube traysSurgical – chest tube trays Medications – Morphine, Valium, Medications – Morphine, Valium,

AtropineAtropine Other disposables – catheters, Other disposables – catheters,

dressings, linensdressings, linens Durable – beds, vents, IV pumps, BP Durable – beds, vents, IV pumps, BP

cuffscuffs

Stuff – Specialty Patient Stuff – Specialty Patient CareCare Example – burnExample – burn

Adaptic dressings Adaptic dressings BacitracinBacitracin Kerlix dressingsKerlix dressings50% BSA burn needs 14 liters 50% BSA burn needs 14 liters

LR/NS in 1LR/NS in 1stst 24h, MS 24h, MS 250mg/24h)250mg/24h)

Persistent SBP < 90mmHg or age-appropriate hypotension unresponsive to fluids

Occasional hypotension or other signs of poor perfusion

No signs of shock

Laboratory or clinical evidence of multiple (> 4) organ system failure*

Laboratory evidence of 2-3 organ system failure

Respiratory failure only

Severe underlying disease with poor short-term prognosis**

Severe underlying disease with poor long-term prognosis and/or ongoing resource demand

No severe underlying disease

Long duration – ARDS, infectious causes of respiratory failure, (estimate > 7 days on ventilator)

Moderate duration – ARDS or infectious cause in healthy patient (estimate 3-7 days on ventilator)

Short duration – flash pulmonary edema, chest trauma, other anticipating < 3 days on ventilator

Worsening oxygenation index***

Stable oxygenation index over time (failure to improve after adequate disease-specific trial of mechanical ventilation)

Improving oxygenation index

Poor prognosis based upon epidemiology of specific disease (eg; pandemic influenza) for patient group.

Indeterminate / intermediate prognosis based upon epidemiology of specific disease process

Good prognosis based upon epidemiology of specific disease

High potential for death according to predictive model

Intermediate potential for death according to predictive model

Low potential for death according to predictive model

Ventilator re-allocated Patient keeps ventilator

Stuff – Support SuppliesStuff – Support Supplies

FoodFood WaterWater Office suppliesOffice supplies UtilitiesUtilities CommunicationsCommunications Oxygen supplyOxygen supply

Surge Capability / Surge Capability / SpecialtySpecialty BurnBurn Chemical / DecontaminationChemical / Decontamination IsolationIsolation PediatricPediatric Blast injury / mass traumaBlast injury / mass trauma Behavioral HealthBehavioral Health

Surge Capacity C S TSurge Capacity C S T

The 4 C’sThe 4 C’s CommandCommand ControlControl CommunicationCommunication

ss CoordinationCoordination

* Surge capacity * Surge capacity CANNOT occur if CANNOT occur if you don’t ‘get all you don’t ‘get all C’s’C’s’

The 4 S’sThe 4 S’s SpaceSpace StaffStaff StuffStuff SpecialSpecial

The 3 T’sThe 3 T’s TriageTriage TreatTreat TransportTransport

‘‘T’ - OperationsT’ - Operations

TriageTriage TreatmentTreatment TransportTransport

TriageTriage

Hospital triage: The most critical Hospital triage: The most critical patients firstpatients first

Mass Casualty triage: The greatest Mass Casualty triage: The greatest amount of good for the largest number amount of good for the largest number of people. Resources used on the victims of people. Resources used on the victims that have the best chance of survivalthat have the best chance of survival

TriageTriage

Location?Location? Triage officerTriage officer Triage tags / initial registration or Triage tags / initial registration or

trackingtracking Locations of care – where are patients Locations of care – where are patients

triaged TO?triaged TO? Key bottlenecks – decontamination, Key bottlenecks – decontamination,

radiology (eg; CT), transportation, OR, radiology (eg; CT), transportation, OR, ICUICU

TreatmentTreatment What patients may be safely treated in What patients may be safely treated in

what areas:what areas: ED, clinics, lobby areas, etcED, clinics, lobby areas, etc

Deal with life-threats only initiallyDeal with life-threats only initially Defer definitive wound closures, fracture Defer definitive wound closures, fracture

reductionsreductions Defer most xrays and labs until demand Defer most xrays and labs until demand

easeseases Use your clinical skills!Use your clinical skills! What is the expectation for What is the expectation for

documentation / nursing orders during documentation / nursing orders during disaster?disaster?

Transportation Transportation Capacity/CapabilityCapacity/Capability

TransportTransport

InternalInternal Transportation from ED to other in-hospital Transportation from ED to other in-hospital

locations (CT, OR, etc)locations (CT, OR, etc) Personnel and resources (beds and Personnel and resources (beds and

wheelchairs, etc)wheelchairs, etc) ExternalExternal

Transport resources – ground, rotor and Transport resources – ground, rotor and fixed wing, alternative ground (WC vans, etc)fixed wing, alternative ground (WC vans, etc)

Referral centers – what’s your backup when Referral centers – what’s your backup when usual partners are full / unable to receive?usual partners are full / unable to receive?

TransportTransport

EMS issuesEMS issues Few communities have adequate EMS Few communities have adequate EMS

resources resources Many EMS personnel have competing Many EMS personnel have competing

demands during disaster (fire demands during disaster (fire department, hospital, family) and may department, hospital, family) and may not be availablenot be available

Few communities have process for Few communities have process for allocation of scarce EMS resourcesallocation of scarce EMS resources

Off-Site Care Facilitiese.g., Procedure Centers,

Churches, Hotels, Community/Recreation Centers, Warehouses

Home

Clinics and/orPrivate MDs

Treatment/Triage

In-Home Family Care

LTC Facilities

Urgent Care Centers

Neighborhood Emergency Help

CentersMass Dispensing Clinics

Screening Centers

Homecare

Hospitals

Surge Capacity Surge Capacity CoordinationCoordination

Community-Community-Based Based SurgeSurge ClinicsClinics Procedure centers (i.e. dialysis Procedure centers (i.e. dialysis

centers)centers) Long Term Care Facilities (LTCFs)Long Term Care Facilities (LTCFs) HomecareHomecare Family-based careFamily-based care Alternative care sitesAlternative care sites Local / Regional referral / NDMSLocal / Regional referral / NDMS

Clinic surge capacityClinic surge capacity Rural – scant ability to increase capacityRural – scant ability to increase capacity Urban – larger ability to increase Urban – larger ability to increase

capacitycapacity Sub-specialty clinicsSub-specialty clinics Surgical centersSurgical centers

Cancellation of elective appointmentsCancellation of elective appointments Changes in hours / staffingChanges in hours / staffing Receiving referrals from hospital?Receiving referrals from hospital?

CriteriaCriteria SuppliesSupplies

Professional HomecareProfessional Homecare

Homecare agenciesHomecare agencies Social workersSocial workers Durable equipment suppliersDurable equipment suppliers Are agencies prepared to prioritize Are agencies prepared to prioritize

services to accommodate increased services to accommodate increased demands?demands?

Do homecare nurses have other Do homecare nurses have other commitments?commitments?

Family-based careFamily-based care

Will be focus of most care in Will be focus of most care in pandemics and pandemics and

General emergency preparedness General emergency preparedness criticalcritical

Specific informationSpecific information

Alternate Care Sites / Alternate Care Sites / Community ActionCommunity Action Neighborhood Emergency Help CenterNeighborhood Emergency Help Center

Screening and minimal care (for example – Screening and minimal care (for example – early pandemic symptoms requiring anti-early pandemic symptoms requiring anti-virals)virals)

Population-based interventionsPopulation-based interventions Acute Care Center / Off-site care facilityAcute Care Center / Off-site care facility

Non-ambulatory care (may also have role as Non-ambulatory care (may also have role as special needs shelter – NH fire, widespread special needs shelter – NH fire, widespread disaster)disaster)

Hospital overflow –allows hospitals to focus Hospital overflow –allows hospitals to focus on critical careon critical care

Many models – adjacent hospital, regional, Many models – adjacent hospital, regional, self-supporting infrastructure vs. existingself-supporting infrastructure vs. existing

Potential Alternative Potential Alternative Care SitesCare Sites Aircraft hangersAircraft hangers Military facilitiesMilitary facilities ChurchesChurches National Guard National Guard

armoriesarmories Community/Community/

recreation centersrecreation centers Surgical centers / Surgical centers /

medical clinicsmedical clinics Convalescent care Convalescent care

facilitiesfacilities

Sports facilities / Sports facilities / stadiumsstadiums

FairgroundsFairgrounds TrailersTrailers Government Government

buildingsbuildings TentsTents Hotels/motelsHotels/motels WarehousesWarehouses Meeting hallsMeeting halls

Factors to considerFactors to consider Ability to lock Ability to lock

down/Securitydown/Security HVACHVAC Lab/specimen handlingLab/specimen handling LightingLighting LaundryLaundry Loading DockLoading Dock Equipment storageEquipment storage Oxygen delivery Oxygen delivery

capabilitycapability Waste disposalWaste disposal ParkingParking Communications Communications

capabilitycapability

Patient deconPatient decon Door sizeDoor size Pharmacy areasPharmacy areas Electrical power with Electrical power with

backupbackup Proximity to hospitalProximity to hospital Family areasFamily areas Toilets/showers/wasteToilets/showers/waste Food supply / prep areaFood supply / prep area Water supplyWater supply Wired for IT/Internet Wired for IT/Internet

accessaccess Primary and Secondary Primary and Secondary

sitessites Controlled accessControlled access

Kansas Alternative Care

Site Selection Matrix

Air

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Chu

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Cen

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Con

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scen

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Fair

grou

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Gov

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Hot

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Mot

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Mee

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Hal

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Nat

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Arm

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ame

Day

Sur

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Cen

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ics

Sch

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Faci

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Trai

lers

/Ten

ts

(Mili

tary

/Oth

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US

AF

Oth

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InfrastructureDoor sizes adequate for gurneys 5

Floors

Loading Dock

Parking for staff and visitors

Roof

Toilet facilities/showers (#)

Ventilation

Security

Walls

Infrastructure

What will Happen at the What will Happen at the Acute Care Alternate Sites?Acute Care Alternate Sites? Triage / admission criteriaTriage / admission criteria Level of care – basic nursing, drip Level of care – basic nursing, drip

meds, IVs, NG feedsmeds, IVs, NG feeds MedicationsMedications Documentation / order managementDocumentation / order management LaboratoryLaboratory Food / water / sanitaryFood / water / sanitary Linen and medical waste handlingLinen and medical waste handling Oxygen?Oxygen?

Sample SiteSample Site

Sample SiteSample Site FoodFood RestroomsRestrooms Staff rehab areasStaff rehab areas SecureSecure HVAC system specsHVAC system specs Paging Paging

/messaging /radio/messaging /radio PowerPower Phone, T1 lines, etc.Phone, T1 lines, etc. City owned!City owned!

HEAD

CHAIR HEADCOTA12

2x2 zip-tied to folding 2x2 zip-tied to folding chairs, shim across chairs, shim across toptop

Nails for chart, IV bagNails for chart, IV bag Cards show team Cards show team

color/letter (eg: green color/letter (eg: green A)A)

Other cards show Other cards show pending orders (red = pending orders (red = stat)stat)

Clothespins/rubber Clothespins/rubber bands hold cardsbands hold cards

Ongoing IssuesOngoing Issues Clinic / outpatient care rolesClinic / outpatient care roles

Legal and RegulatoryLegal and Regulatory

ReimbursementReimbursement

Workforce coordination with public healthWorkforce coordination with public health

Credentials / HR issuesCredentials / HR issues

Section 3: Section 3: Selected Surge Selected Surge Situations and Situations and Special TopicsSpecial Topics

Overview – Section 3Overview – Section 3

Event-specificEvent-specific

Behavioral healthBehavioral health

SecuritySecurity

Education and trainingEducation and training

ScenarioScenario 23 year old presents to ED 23 year old presents to ED

– just arrived from Africa– just arrived from Africa Bleeding from everywhere Bleeding from everywhere

– sclera, gums, GI tract, – sclera, gums, GI tract, genitourinary tract, genitourinary tract, bruising skin notedbruising skin noted

Febrile to 101Febrile to 101 Sister who traveled with Sister who traveled with

her is also feeling ill but her is also feeling ill but has no signs yet of her has no signs yet of her sister’s illnesssister’s illness

What do you do?What do you do?

IsolationIsolation SpaceSpace

Triage and screening – location, processTriage and screening – location, process Treatment areas – iso rooms, cohortingTreatment areas – iso rooms, cohorting

Staff - training, call-in, monitor compliance Staff - training, call-in, monitor compliance with PPE, communicationswith PPE, communications

Stuff – antibiotics, anti-virals, analgesia / Stuff – antibiotics, anti-virals, analgesia / sedation, ventilators, PPE suppliessedation, ventilators, PPE supplies

Special – security, communications, family Special – security, communications, family issuesissues

Transport – internal and external issues - Transport – internal and external issues - processprocess

ScenarioScenario Workers at construction Workers at construction

site unearth large jar of site unearth large jar of clear liquid – they pick clear liquid – they pick the jar up and it the jar up and it shattersshatters

Both workers are Both workers are splashed and have splashed and have immediate respiratory immediate respiratory distress as well. Much distress as well. Much of the liquid vaporizes.of the liquid vaporizes.

EMS removes clothing EMS removes clothing and transports as no and transports as no decon available and decon available and respiratory distressrespiratory distress

What do you do?What do you do?

ChemicalChemical

Space – decontamination, triage, Space – decontamination, triage, treatment spacetreatment space

Staff – trained for decontamination, ED Staff – trained for decontamination, ED staff, ICU (if applicable), monitoring of staff, ICU (if applicable), monitoring of PPE use / dutiesPPE use / duties

Stuff – antidotes (particularly atropine Stuff – antidotes (particularly atropine and 2PAM), analgesia, sedation, PPE, and 2PAM), analgesia, sedation, PPE, vents / ICUvents / ICU

Special – decontamination equipment, Special – decontamination equipment, runoff issuesrunoff issues

ScenarioScenario Tornado watch issued at Tornado watch issued at

noon for your citynoon for your city Tornado warning at 4pm Tornado warning at 4pm

– staff and patients – staff and patients shelter in placeshelter in place

Severe damage to large Severe damage to large neighborhood in neighborhood in community, hospital community, hospital multiple windows multiple windows broken, reports of broken, reports of leaking roof in one unit, leaking roof in one unit, electricity out except electricity out except emergency poweremergency power

What do you do?What do you do?

TornadoTornado Command – assess impact on facility / Command – assess impact on facility /

staffstaff Space – triage areas, treatment areas – Space – triage areas, treatment areas –

expand capacity especially outpatientexpand capacity especially outpatient Staff – shift staffingStaff – shift staffing Stuff – Tdap boosters, analgesia, Stuff – Tdap boosters, analgesia,

sedation, local anesthetics, suture trayssedation, local anesthetics, suture trays Special – debris removal, utilities Special – debris removal, utilities

support, staff transportationsupport, staff transportation Transportation – EMS resourcesTransportation – EMS resources

ScenarioScenario Office building explodesOffice building explodes Several persons trapped Several persons trapped

in rubble, at least 2 in rubble, at least 2 fatalities – 2 of injured fatalities – 2 of injured dragged out and dragged out and brought by private car brought by private car to hospitalto hospital

Multiple walking Multiple walking wounded including wounded including some people walking on some people walking on the street / in cars and the street / in cars and hit by debrishit by debris

Few windows broken in Few windows broken in hospital complexhospital complex

Bomb / Blast injuryBomb / Blast injury

Command – facility assessment?Command – facility assessment? Space – triage area, treatment, ORSpace – triage area, treatment, OR Staff – including specialty – ENT, eye, Staff – including specialty – ENT, eye,

surgerysurgery Stuff – analgesia, sedation, Tdap, burn Stuff – analgesia, sedation, Tdap, burn

supplies (adaptic, narcotics, ibuprofen, supplies (adaptic, narcotics, ibuprofen, bacitracin), surgical supplies (suture trays, bacitracin), surgical supplies (suture trays, chest tube)chest tube)

Special – security, behavioral health, Special – security, behavioral health, familyfamily

Other Surge ChallengesOther Surge Challenges

‘‘Upside down triage’Upside down triage’ Family membersFamily members Communications / informationCommunications / information MediaMedia Psychological casualtiesPsychological casualties

IN-HOUSEIN-HOUSEDistressed StaffDistressed Staff

INPATIENTINPATIENTDistressed InpatientsDistressed Inpatients Family MembersFamily Membersof Inpatientsof Inpatients

INCOMINGINCOMING

Behavioral Health Surge Behavioral Health Surge DemandsDemands

MediaMedia VolunteersVolunteers OnlookersOnlookers

PsychologicalPsychologicalCasualtiesCasualties

EMS-EMS-ProcessedProcessed

MedicalMedicalCasualtiesCasualties

Self-TransportedSelf-TransportedMedical CasualtiesMedical Casualties

Bystanders orBystanders orFamilyFamily

Members,Members,Friends,Friends,

Co-workersCo-workersof Incomingof IncomingCasualtiesCasualties

Family MembersFamily MembersSearchingSearchingfor Missingfor MissingLoved OnesLoved Ones

Injured,Injured,Exposed,Exposed,

DistressedDistressedDisaster/Disaster/

EmergencyEmergencyWorkersWorkers

Behavioral Health SurgeBehavioral Health Surge SortingSorting

Triage psychological (or likely) to Triage psychological (or likely) to observation areaobservation area

SupportingSupporting Quiet areaQuiet area Food and liquidsFood and liquids Family support area as wellFamily support area as well

ServicesServices Chaplaincy, social work, Chaplaincy, social work,

psychology/psychiatry, CISM, psychological psychology/psychiatry, CISM, psychological first aidfirst aid

Observe, screen, refer as neededObserve, screen, refer as needed

AftereffectsAftereffects

Continued high ER Continued high ER and clinic volumesand clinic volumes

Psychological Psychological stressorsstressors

Unique hazards Unique hazards may affect health may affect health after the eventafter the event

NYC post 9-11-01NYC post 9-11-01

22.5% increase in asthma over 5-9 22.5% increase in asthma over 5-9 weeks younger patients, 44% > 54 weeks younger patients, 44% > 54 yrsyrs

75% in random phone survey 75% in random phone survey reported adverse psychological reported adverse psychological effectseffects

MMWR Sept. 6, 2002MMWR Sept. 6, 2002

SecuritySecurity

LockdownLockdown Ingress / egress controlIngress / egress control Staff:Staff:

HospitalHospital ContractContract Public SafetyPublic Safety Community sourcesCommunity sources

Policies and procedures – weapons, Policies and procedures – weapons, crowd control, use of forcecrowd control, use of force

Education and TrainingEducation and Training

Hospital Incident Command TrainingHospital Incident Command Training Just-in-Time TrainingJust-in-Time Training DrillsDrills

TabletopTabletop FunctionalFunctional

What do I do now?What do I do now?

Next StepsNext Steps ReviewReview

Your Emergency Operations PlanYour Emergency Operations Plan Incorporate Incident CommandIncorporate Incident Command Clearly define what a hospital employee will DOClearly define what a hospital employee will DO Have current job actions sheets and reporting Have current job actions sheets and reporting

formsforms Request more training in Incident Command if Request more training in Incident Command if

neededneeded Imbed Incident Command in daily operations Imbed Incident Command in daily operations

Next Steps to SurgeNext Steps to Surge

Define your Surge Capacity PartnersDefine your Surge Capacity Partners Make sure they know what you expect Make sure they know what you expect

of them.of them. Identify federal assetsIdentify federal assets Acquire the needed bed-tracking Acquire the needed bed-tracking

program & trainingprogram & training Create a Pre-surge planCreate a Pre-surge plan

If time allows: If time allows:

Surge “Capacity”Surge “Capacity”

SpaceSpace Evaluate your physical facilityEvaluate your physical facility

Space for cots, family, media, staff respite Space for cots, family, media, staff respite BH …BH …

Evaluate near-by external facilitiesEvaluate near-by external facilities Create guidelines for early dismissalsCreate guidelines for early dismissals

Surging PersonnelSurging Personnel

StaffStaff Determine ways to reallocate internal Determine ways to reallocate internal

staff rolesstaff roles Determine external staffing optionsDetermine external staffing options

Determine process for assigning Determine process for assigning mentors/preceptorsmentors/preceptors

Plan Staff ExtendersPlan Staff Extenders Just-In-Time TrainingJust-In-Time Training

Considering SuppliesConsidering Supplies

StuffStuff Create a plan for a quick inventoryCreate a plan for a quick inventory

PPEPPE General Patient Care Supplies – include General Patient Care Supplies – include

medicationsmedications Specialty Patient SuppliesSpecialty Patient Supplies Support Supplies Support Supplies

Food, water, office, communicationFood, water, office, communication

Create a plan to begin stockpiling Create a plan to begin stockpiling

Planning for the T’sPlanning for the T’s

TriageTriage Train in Mass-Casualty TriageTrain in Mass-Casualty Triage Plan triage areas, internal and externalPlan triage areas, internal and external Locate Vests and TagsLocate Vests and Tags

TreatmentTreatment Discuss and plan for temporary Discuss and plan for temporary

treatment of non-life-threatening treatment of non-life-threatening injuries.injuries.

Discuss alternative record-keeping Discuss alternative record-keeping

TransportationTransportation InternalInternal

Determine number and location of Determine number and location of wheelchairs/gurneyswheelchairs/gurneys

Plan for alternate modes of transportationPlan for alternate modes of transportation ExternalExternal

Know your local transport resourcesKnow your local transport resources Plan for alternate modes of transportationPlan for alternate modes of transportation

Community Based SurgeCommunity Based Surge

Coordinate with local Public HealthCoordinate with local Public Health Determine your roleDetermine your role Identify existing plansIdentify existing plans

Revisit Parking Lot Revisit Parking Lot IssuesIssues

Please fill out your evaluations Please fill out your evaluations and and

Self AssessmentSelf Assessment

Thank you for Thank you for Coming!Coming!